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RDil  Su7  Surgical  clinics  i 


RECAP 


IN  HONOR 

OF 

DR.  LEWIS  STEPHEN  PILCHER 

1917 


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College  of  ^ijpgiciansi  mh  burgeons; 

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Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

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http://www.archive.org/details/surgicalclinicscOOmedi 


IN  HONOR 

OF 

DR.  LEWIS  STEPHEN  PILCHER 


SURGICAL  CLINICS 


AND 


CLINICAL    REPORTS 


IN  HONOR  OF 


LEWIS  STEPHEN  PILCHER 


Being  the  Reports  of  Surgical  Clinics  at  the  Hospitals 
and  Clinical  Monographs  by  Surgeons  in  Brooklyn, 
New  York,  to  commemorate  the  completion  of  his 
fifty    years    of    service    as    a   doctor    of    medicine. 


PUBLISHED  BY  THE  MEDICAL  SOCIETY  OF  THE  COUNTY 
OF  KINGS,  NEW  YORK. 

1917 


-KJ>\ 

i-1 


PREFACE 

On  the  28th  of  March,  1866,  Lewis  Stephen  Pilcher  received  the 
degree  of  Doctor  of  Medicine  from  the  University  of  Michigan,  and 
entered  upon  a  career,  which  now  for  fifty  years  has  been  charac- 
terized by  devotion  to  the  high  ideals  which  have  won  for  him  the 
esteem  of  his  profession  and  the  honor  and  respect  of  the  public. 

On  the  eve  of  the  fiftieth  anniversary  of  his  entering  the  medical 
profession,  the  Medical  Society  of  the  County  of  Kings,  in  New 
York,  appointed  a  committee  to  arrange  for  a  suitable  celebration  of 
the  event.  A  banquet  was  held  on  the  12th  of  May,  and  on  the  11th, 
12th  and  13th  of  May,  Surgical  Clinics  were  held  in  the  hospitals  of 
Brooklyn  and  surgical  addresses  were  delivered  by  Brooklyn  sur- 
geons in  his  honor. 

It  was  to  Brooklyn  in  1866  that  Dr.  Pilcher  came  to  begin  his 
medical  career.  It  was  at  the  Naval  Hospital  in  Brooklyn  that  he  en- 
tered upon  the  duties  of  the  physician.  In  this  community  he  has 
practiced  his  profession  for  forty-two  years,  and  for  the  past  twenty- 
seven  years  has  devoted  himself  exclusively  to  surgical  work. 

This  volume  is  a  simple  expression  of  the  alifection  and  respect  of 
his  surgical  colleagues  who  are  his  neighbors.  The  great  world  of 
surgery  outside  of  his  own  community  has  been  glad  to  do  him 
honor.  The  surgeons  who  are  his  neighbors  have  been  the  chief  re- 
cipients of  his  benefactions  because  they  have  enjoyed  the  privilege  of 
living  and  working  within  the  close  circle  of  his  inspiring  influence. 

This  volume  contains  the  reports  of  the  surgical  clinics  and 
surgical  addresses  given  in  honor  of  the  man  and  the  occasion. 

James  P.  Warbasse, 
Rai^ph  H.  Pomkroy. 

Committee. 


UNITED  STATES  NAVAL  HOSPITAL  OF  BROOKLYN. 

NEW  YORK 


SURGICAL  CLINICS,  HELD  AT  THE  U.  S.  NAVAL  HOS- 
PITAL, BROOKLYN,  NEW  YORK. 

Philip  Leach,  M.D.,  Medical  Director,  U.  S.  N. 

C.  M.  Oman,  M.D.,  Executive  Surgeon,  U.  S.  N. 

E.  P.  Halton,  M.D.,  Passed  Assistant  Surgeon,  U.  S.  N. 

H.  F.  Lawrence,  M.D.,  Passed  Assistant  Surgeon,  U.  S.  N. 

Disi,oCATioN  OF  Intra- Articular  Cartilage  of  Knee-Joint. 

N ,  C.S.,  Ordinary  Seaman ;  age  19 ;  white. 

This  man  was  admitted  from  the  U.S.S.  Nevada,  April  15,  1916, 
with  a  diagnosis  of  dislocation  of  an  intra-articular  cartilage  of  the 
right  knee  joint. 

History. — While  exercising  in  the  gymnasium  in  November, 
1915,  he  fell  from  parallel  bars  and  struck  on  the  inner  right  knee. 
He  states  that  he  got  up  and  walked  immediately  but  that  the  knee 
felt  sore  and  painful.  It  was  not  "locked."  He  was  put  to  bed  at 
this  time  and  remained  in  bed  for  three  weeks,  receiving  the  usual 
hot  applications  and  liniments.  At  the  end  of  this  time  he  felt  much 
relieved  and  according  to  his  statement,  the  pain  and  stiffness  had 
practically  disappeared.  However,  on  resuming  his  duties  he  noticed 
that  this  knee  was  distinctly  troublesome  and  that  he  continually  had  a 
sensation  of  uncertainty  as  to  the  manner  in  which  this  joint  was 
going  to  act.  Eight  times  since  November,  1915,  the  joint  has  be- 
come "locked"  in  a  semi-flexed  position,  but  he  has  always  been 
able  to  straighten  it  out  himself  by  manipulation.  The  last  time 
"locking"  occurred  was  one  week  ago. 

During  the  past  two  weeks  he  has  occasionally  complained  of 
pain  and  stiffness  in  the  joint. 

Physical  Examination. — Examination  shows  very  little  difference 
in  the  contour  of  the  two  knee  joints;  and  there  are  no  signs  of 
effusion.  There  is  distinct  tenderness  over  the  position  of  the  right 
internal  cartilage.     X-ray  examination  is  negative. 

Operation  by  Surgeon  C.  M.  Oman,  U.S.  Navy. — Ether  anes- 
thesia. A  3'''  longitudinal  incision  is  made  over  internal  cartilage :  and 
what  hemorrhage  there  is  is  controlled  by  ligatures.  Capsule  of 
joint  opened  and  immediately  the  internal  cartilage  is  seen  detached 
from  its  normal  position  and  hanging  in  joint,  detached  at  both  ends. 
Care  is  taken  to  use  instruments  alone  in  the  joint,  not  touching  with 
fingers.  The  cartilage  is  cut  at  each  end  and  removed.  Knee  joint 
flexed  and  extended  to  observe  condition  and  to  see  that  no  loose 
bodies  are  present.  Capsule  closed  accurately  with  fine  catgut  and  a 
curved  needle.  External  wound  closed  by  interrupted  silk-worm  gut 
sutures.  Dry  sterile  dressing  applied  and  joint  supported  by  a  long 
posterior  splint. 

The  splint  will  remain  on  for  three  weeks.  Then  the  patient 
will  be  allowed  to  walk  on  crutches  for  two  weeks,  and  at  the  end 


of  five  weeks  from  the  time  of  operation  he  will  be  allowed  to  bear 
his  weight  gradually  on  this  leg. 

Comments  by  Operating  Surgeon. — The  above  is  a  typical  history 
of  many  cases  which  are  being  treated  for  "sprains,"  "rheumatism," 
etc.,  which  really  are  dislocated  cartilages.  It  is  a  well-known  fact 
that  the  internal  cartilage  is  usually  the  one  dislocated,  due  to  the 
anatomical  arrangement  of  the  joint. 

It  has  been  very  rare  in  my  experience  to  feel  any  projection  on 
the  surface  and  never  have  I  been  able  to  fix  a  cartilage  before 
operating,  as  is  mentioned  in  some  works  on  surgery. 

Of  course  it  is  needless  to  say  that  strict  asepsis  should  be  fol- 
lowed. We  have  operated  on  a  number  of  these  cases  and  have  never 
seen  any  ill  results.  In  fact,  all  the  patients  have  resumed  their 
active  duty  on  board  of  seagoing  vessels  without  any  discomfort.  I 
have  been  able  to  follow  up  a  number  of  my  operations  on  this  condi- 
tion for  a  period  of  six  or  seven  years,  and  all  the  results  have  been 
satisfactory. 

It  seems  to  me  that  a  great  many  surgeons  are  a  little  shy  in 
opening  the  knee  joint  for  this  disabling  condition;  they  seem  to 
retain  the  extreme  fear  and  dread  which  were  formerly  felt  when  the 
knee  joint  was  operated  upon. 

Adenoma  of  Male  Breast. 

S ,  S.,  Machinist's  Mate  2nd  class ;  age  23 ;  white. 

This  man  was  admitted  from  the  U.S.S.  Ontario,  April  20,  1916, 
with  a  diagnosis  of  adenoma,  left  breast. 

History. — In  191 2  he  first  noticed  a  swelling  in  the  left  breast 
which  seemed  to  him  as  an  enlargement  of  the  whole  breast.  The 
next  day  the  swelling  had  disappeared.  Six  months  later  the  swelling 
again  appeared,  and  has  been  present  ever  since.  At  times,  after 
working  hard,  the  breast  became  red  and  painful.  Usually  it  caused 
him  only  slight  discomfort,  and  this  was  more  or  less  imaginary. 
There  never  has  been  any  discharge  from  the  nipple  and  no  ex- 
coriation about  the  breast. 

Physical  Examination. — Physical  examination  shows  a  firm  mov- 
able mass,  regular  in  outline  and  rather  firm  in  consistency,  about  the 
size  of  an  orange  and  not  adherent  to  the  skin  or  muscles.  No  secre- 
tion can  be  expressed  from  the  nipple.  It  is  tender  on  manipulation. 
The  diagnosis  of  adeno-fibroma  is  made. 

Operation  by  Surgeon  C.  M.  Oman,  U.S.  Navy. — Ether  anesthe- 
sia. The  whole  breast  was  amputated  by  the  usual  incisions.  Very 
little  hemorrhage.  Wound  closed  by  interrupted  silk  worm  gut  and 
arm  bandaged  to  side  after  dressings  were  applied. 

Varicocele.  - 

S ,  R.  T.,  Chief  Machinist's  Mate ;  age  28 ;  white. 

This  man  was  admitted  from  the  U.S.S.  Winslow,  April  29,  1916, 
with  a  diagnosis  of  varicocele,  left. 

History. — He  gives  the  usual  signs  and  symptoms  of  a  moderate 
varicocele  and  recently  it  has  caused  him  considerable  pain  and  the 
usual  mental  worry. 

Physical  Examination. — Examination  shows  moderately  enlarged 
veins  in  left  scrotum. 

10 


operation  by  Surgeon  C.  M.  Oman,  US.  Navy. — Ether  anes- 
thesia. High  operation.  A  2''  incision  made  over  external  ring; 
testicle  dislocated  into  wound ;  the  vas,  a  couple  of  small  veins,  and 
the  cremasteric  muscle  separated;  veins  ligated  and  transfixed;  about 
2^"  removed  and  ends  brought  together  by  a  double  ligature  of  cat- 
gut. The  tunica  vaginalis  cut  with  scissors  and  everted.  The 
testicle  returned  to  scrotum  and  the  wound  closed  by  deep  fascial 
catgut  sutures,  and  three  superficial  silk  worm  gut  sutures.  Dry 
dressings  and  support  of  testicle.  Patient  will  be  in  bed  for  one 
week. 

Comments  by  Operating  Surgeon. — We  have  found  that  this 
method  of  doing  this  operation  gives  very  satisfactory  results.  The 
dislocation  of  the  testicle  permits  one  to  get  at  the  diseased  veins,  and 
the  cutting  of  the  tunica  vaginalis  not  only  does  away  with  swelling 
of  the  testicle  after  the  operation  but  absolutely  prevents  the  forming 
of  a  hydrocele  some  weeks  or  months  later.  It  is  a  very  quick  opera- 
tion, usually  taking  about  seven  to  eight  minutes. 

Depressed  Scar,  FoIvI/)wing  Maxillary  Sinus. 

B ,  J.  H.,  Chief  Electrician;  age  39;  white. 

This  man  was  admitted  from  the  U.S.S.  Florida,  October  15, 

1915,  with  a  diagnosis  of  depressed  maxillary  scar. 

History. — He  has  had  a  chronic  sinus  of  the  right  lower  jaw 
about  seven  years.  During  the  past  few  months  he  has  had  the  wound 
opened  and  the  lower  maxilla  scraped.  No  dead  bone  found.  The 
roots  of  two  teeth  had  been  removed.  The  sinus  ceased  discharging 
some  weeks  ago  and  the  external  wound  is  entirely  healed,  leaving  a 
depressed  scar  attached  to  the  jaw  bone. 

Operation  by  Passed  Assistant  Surgeon  H.  F.  Lawrence,  U.S. 
Navy. — Novocaine  anesthesia.  A  2.5  cm.  (i  inch)  linear  incision 
made  down  to  jaw  bone.  All  the  tissues  were  freely  separated  and 
the  wound  closed  by  three  silk-worm  gut  sutures  in  such  a  way  as  to 
lift  up  the  depressed  portion  of  the  scar  and  leave  a  wound  in  which 
the  scar  should  be  level  with  the  adjacent  surface. 

Deflected  Nasal  Septum. 

Case  I.  S ,  G.  H.,  Chief  Carpenter's  Mate ;  age  30 ; 

white. 

This  man  was  admitted  from  the  U.S.S.  Prometheus,  April  8, 

1916,  with  a  diagnosis  of  deflected  nasal  septum. 

History. — He  has  complained  of  nasal  obstruction  for  some  years, 
and  has  had  the  usual  disagreeable  symptoms  on  catching  a  fresh  cold. 

Physical  Examination. — A  marked  deflection  of  septum  to  the 
right  is  discovered. 

Operation  by  Passed  Assistant  Surgeon  B.  P.  Helton,  U.S.  Navy, 
Retired. — Cocaine  anesthesia.  Submucus  resection  of  septum  per- 
formed. 

Case  n.  W ,  H.  C,  Seaman ;  age  22 ;  white. 

This  man  was  admitted  from  the  U.S.S.  Wyoming,  May  5,  1916, 
with  a  diagnosis  of  deflected  nasal  septum. 

History. — He  has  complained  of  the  usual  symptoms  resulting 
from  obstruction  of  the  nasal  cavities. 

Physical  Examination. — There  was  a  marked  deflection  of  the 
nasal  septum  with  an  old  chronic  ulceration  on  the  septum. 

11 


operation  by  Passed  Assistant  Surgeon  B.  P.  Halton,  U.S.  Navy, 
Retired. — Cocaine  anesthesia.  Submucus  resection  of  septum  per- 
formed. 

Deviation  o^  Nasal  Septum. 

K ,  S.  G.,  Seaman;  age  21;  white. 

This  man  was  admitted  from  the  U.  S.  S.  Wyoming,  May  2,  19 16, 
with  a  diagnosis  of  irregular  deviation  of  nasal  septum. 

History. — He  complains  of  the  usual  obstructive  symptoms  and 
mouth  breathing  at  night. 

Examination. — Shows  a  markedly  deviated  septum  to  left. 

Operation  by  Passed  Assistant  Surgeon  E.  P.  Halton,  U.  S.  Navy, 
Retired. — Cocaine  anesthesia.  Submucus  resection  of  septum  per- 
formed. 

Hypertrophibd  Tonsils  and  Adenoids. 

M ,  N.,  Female;  age  9^;  white. 

This  child  is  a  daughter  of  a  Marine  Officer.  Diagnosis:  Hyper- 
trophy of  tonsils  and  adenoids. 

Operation  by  Passed  Assistant  Surgeon  E.  P.  Halton,  U.  S.  Navy, 
Retired. — Ether  anesthesia.  Tonsils  removed  by  dissection  and  cold 
wire  snare.     Curettement  of  masses  of  adenoids. 

Double  Inguinal  Hernia. 

L ,  M.  G.,  Gunner's  Mate  2d  class ;  age  24;  white. 

•    This  man  was  admitted  from  the  U.S.S.  Arkansas,  May  10,  1916, 
with  a  diagnosis  of  a  left  inguinal  hernia. 

History. — Patient  had  been  operated  on  for  a  left  inguinal  hernia 
in  August,  1913.  One  month  ago  he  noticed  a  swelling  at  the  site 
of  the  old  scar. 

Physical  Examination. — Examination  reveals  a  small  reducible 
indirect  left  hernia  at  the  site  of  the  previous  operation.  Examina- 
tion also  shows  a  small  indirect  reducible  right  inguinal  hernia.  He 
has  not  been  aware  of  the  presence  of  this  hernia. 

Operation  by  Surgeon  C.  M.  Oman,  U.  S.  Navy. — Ether  anes- 
thesia. A  Bassini  operation  performed  on  each  side  with  the  Kocher 
modification.  A  small  sac  containing  omentum  present  on  left  side 
and  a  small  sac  found  on  right  side. 

Comments  by  Operating  Surgeon. — This  patient  will  be  kept  in 
bed    for    two    weeks. 

Chronic  Bursitis  of  Toe. 

C ,  J.  D.,  Bugler;  age  30;  white. 

This  man  was  admitted  from  the  U.  S.  S.  Maine,  May  2,  1916,  with 
a  diagnosis  of  bursitis,  chronic,  metatarsophalangeal  joint,  left  foot. 

History. — For  the  past  year  the  patient  has  been  troubled  with 
pain,  redness  and  swelling  over  this  region.  The  pain  becomes  much 
worse  on  standing  for  any  length  of  time  or  upon  taking  the  usual 
"hike." 

Physical  Examination. — Shows  swelling,  redness  and  tenderness 
over  the  inner  side  of  joint.     Practically  no  deformity  of  joint. 

Operation  by  Passed  Assistant  Surgeon  H.  F.  Lawrence,  U.  S. 
Navy. — Ether  anesthesia.     Excision  of  bursa. 

12 


Hemorrhoids. 

Case  I.  W ,  F.  J.,  Gunner's  Mate  3rd  class;  age  26; 

white. 

This  man  was  admitted  from  the  U.  S.  S.  Wyoming,  May  9,  1916, 
with  a  diagnosis  of  hemorrhoids. 

History. — Five  years  ago  this  patient  was  operated  upon  for  a 
similar  condition.  One  week  ago  the  hemorrhoids  again  became 
prominent.    There  is  some  protrusion  and  they  bleed. 

Physical  Examination. — Shows  two  large  bleeding  internal  hem- 
orrhoids   that    cannot   be   replaced. 

Operation  by  Passed  Assistant  Surgeon  H.  F.  Lawrence,  U.  S. 
Navy. — Ether  anaesthesia.  Sphincter  dilated  for  5  minutes.  Clamp 
and  cautery  applied  to  two  sections.  One  mass  ligated  by  catgut 
ligature  and  removed  by  scissors.     Iodoform  and  opium  suppositories. 

Comment  by  Operating  Surgeon. — Bowels  will  be  kept  bound  up 
for  four  days.  Patient  will  be  allowed  up  after  one  week  and  advised 
as  to  regularity  to  prevent  future  trouble. 

Case  II. — S ,  C.  G.,  Boatswain's  Mate  2nd  class;  age 

26;  white. 

This  man  was  admitted  from  the  U.  S.  S.  Utah,  May  9,  19 16,  with 
a  diagnosis  of  hemorrhoids. 

History. — About  one  week  ago  patient  first  noticed  small  bleed- 
ing, protruding  mass. 

Physical  Examination. — Shows  a  small  external  pile  and  two 
small  internal  piles. 

Operation  by  Surgeon  C.  M.  Oman,  U.  S.  Navy. — Ether  anes- 
thesia. Sphincter  dilated  for  5  minutes.  Clamp  and  cautery  applied 
to    two    sections. 

Acute   Appendicitis. 

H ,  F.  A.,  Ordinary  Seaman;  age  20;  white. 

This  man  was  admitted  from  the  U.  S.  S.  Wyoming  today,  with 
a  diagnosis  of  acute  appendicitis. 

History. — Gives  a  history  of  having  had  acute  appendicitis  two 
months  ago.  Last  night  he  was  taken  with  pain  in  right  iliac  region, 
vomiting  and  fever. 

Physical  Examination. — Temperature  98.8,  respiration  20, 
leucocytes  30,000,  polymorpho-nuclears  90  per  cent,  urine  normal. 
There  is  tenderness  and  rigidity. 

Operation  by  Surgeon  C.  M.  Oman,  U.  S.  Navy. — Ether  anes- 
thesia. Gridiron  incision,  below  and  external  to  classical  McBurney 
incision.  There  is  a  marked  increase  in  peritoneal  fluid.  Appendix 
acutely  inflamed,  large,  and  surrounded  by  plastic  lymph.  Ligated. 
Stump  cauterized  and  returned  to  abdominal  cavity.  Wound  closed 
in  usual  manner. 

Comment  by  Operating  Surgeon. — This  man  will  be  kept  in  bed 
for   ten   days. 

Acute  Appendicitis. 

C ,  N.,  Private  Marine;  age  33;  white. 

This  man  was  admitted  from  this  hospital.  May  12,  19 16.  He 
is  a  member  of  our  marine  guard. 

13 


History. — He  was  taken  sick  three  days  ago  with  a  pain  in  the 
region  of  gall  bladder.  He  was  slightly  jaundiced  at  the  time.  No 
symptoms  referable  to  the  appendix  at  that  time.  He  was  given  the 
usual  purgatives.  He  felt  fairly  well  until  last  night  when  he  began 
to  have  violent  pains  in  the  abdomen  which  became  locaHzed  in  the 
right  iliac  region  this  morning.     He  vomited. 

Physical  Examination. — There  was  tenderness  over  region  of 
appendix,  some  rigidity.  He  states  he  has  had  a  similar  trouble  once 
before.    Skin  jaundiced.    No  tenderness  over  gall  bladder. 

Operation  by  Passed  Assistant  Surgeon  H.  F.  Lawrence,  U.S. 
Mavy. — Ether  anesthesia.  Gridiron  incision.  Peritoneal  fluid  in- 
creased; appendix  bound  closely  to  cecum  and  enlarged  meso-appen- 
dix,  short  and  very  thick.  Appendix  removed  by  dissection.  Stump 
cauterized  and  gut  returned  to  abdomen. 


14 


II 

SAINT  CATHARINE'S  HOSPITAL. 


CLINIC  AT   SAINT  CATHARINE'S   HOSPITAL. 
James  C.  Kennedy,  M.D.,  F.A.C.S. 

Gentlemen:  This  clinic  is  held  in  honor  of  Dr.  Lewis  Stephen 
Pilcher,  one  of  our  most  distinguished  confreres.  He  has  now  reached 
his  fiftieth  anniversary  as  a  practicing  surgeon. 

His  useful  life  as  a  highly  respected  citizen,  an  earnest  and 
competent  surgeon,  and  as  editor  of  a  widely  circulated  surgical  journal, 
has  given  him  a  high  place  in  the  esteem  of  the  people  of  our  city 
and  of  his  medical  and  surgical  colleagues.  By  his  teaching  and 
example,  always  the  true  surgeon  and  gentleman,  the  distinguished 
editor  and  scholar,  he  has  justly  earned  his  place  among  the  great 
men  of  modem  times.  This  clinic,  comparatively  insignificant,  will 
evidence  the  gratitude  of  myself  and  my  colleagues  of  Saint  Cathar- 
ine's Hospital  for  the  great  work  Dr.  Pilcher  has  done  throughout  a 
long  and  honorable  career. 

Chronic  Appendicitis:   Gali*  Stones. 

The  first  patient  for  operation  this  morning  is  this  slenderly  built 
woman,  whose  age  is  thirty-nine  years.  She  was  born  in  this  country, 
and  is  the  mother  of  two  children ;  she  has  menstruated  regularly  and 
has  never  had  any  miscarriages.  Her  previous  history  is  negative, 
except  for  the  diseases  of  childhood.  She  states  that  two  years  ago 
she  began  to  have  attacks  of  pain  in  the  right  iliac  fossa,  and  that, 
in  addition  she  has  had  almost  a  constant  feeling  of  fullness  and 
heaviness  in  the  right  hypochondrium,  accompanied  by  a  dragging 
sensation  over  the  hepatic  area.  This  patient  was  sent  into  the  hospital 
with  a  diagnosis  of  chronic  appendicitis  which  we  believed  to  be  cor- 
rect; still  we  do  not  believe  that  all  the  symptoms  stated  are  due  to 
appendicitis.  Laboratory  findings  together  with  the  x-ray  examina- 
tion, are  negative.  However,  in  the  prone  position,  palpation  over 
the  region  of  the  gall  bladder  elicits  soreness,  but  not  sharp  pain ;  the 
same  is  found  in  that  portion  of  the  liver,  bounding  the  gall  bladder. 
These  are  two  symptoms  that  I  hold  in  high  regard  in  gall  bladder 
disease.  She  has  never  had  biliary  colic  or  jaundice,  but  when  the 
abdomen  is  open  we  must  not  forget  to  examine  the  gall  bladder. 

Our  incision  is  made  below  the  umbilicus,  through  the  right  rectus 
muscle.  We  are  now  in  the  peritoneal  cavity,  and  find  a  chronically 
inflamed  appendix  which  we  will  remove;  the  stump  is  inverted  ac- 
cording to  the  Dawbarn  method.  I  now  place  my  right  gloved  hand 
into  the  peritoneal  cavity;  the  uterus  and  ovary  are  correct, — now 
upward,  and  I  find  everything  normal,  with  the  exception  of  the  gall 
bladder  which  is  filled  with  calculi.  We  will  now  close  our  appendiceal 
wound,  and,  using  the  Mayo  Robson  incision,  do  a  cholecystostomy 
for  cholelithiasis.  On  opening  the  gall  bladder  in  the  usual  way  I  am 
able  to  remove  these  stones  with  the  forceps.  Each  stone,  as  you  see, 
is  about  the  size  of  a  small  bird's  egg.    'This  is  the  last  one,  making 

17 


thirty-two  calculi  in  all.     With  the  duets  now  freed,  we  will  drain 
the  gall  bladder  as  it  is  done  ordinarily. 

We  all  know  that  calculi  may  exist  in  the  gall  bladder  or  in  some 
portions  of  the  bile  ducts  without  giving  rise  to  any  symptoms,  or  at 
least  so  few  that  it  is  almost  impossible  to  make  a  diagnosis  of  their 
existence.    This  statement  is  borne  out,  in  some  degree,  by  this  case. 

GaIvI.  Stonr  Disease. 

Here  is  another  operation  for  gall  bladder  disease,  but  it  differs 
materially  from  the  case  we  have  just  concluded.  The  patient  is  a 
stout  lady,  and  on  referring  to  the  History  we  find  her  weight  to  be 
l8o  pounds,  her  age  is  fifty  years,  she  was  born  in  this  country,  and 
is  the  mother  of  four  children.  There  is  a  scar  in  the  lower  abdomen, 
but  the  patient  was  unable  to  state  the  reason  for  the  operation  which 
it  marks.  She  has  had  paroxysms  of  pain,  chills  and  jaundice  for 
four  years.  From  the  time  of  her  arrival  at  the  hospital  she  has  had 
all  the  classical  symptoms  of  obstructed  gall  bladder  disease. 

On  opening  the  abdomen,  we  find,  with  the  exception  of  the 
hepatic  ducts,  that  the  biliary  canal  is  filled  with  calculi.  Since  this 
is  so,  the  obstruction  to  the  flow  of  bile  into  the  intestinal  canal  must 
be  in  the  common  duct — here  is  a  large  stone  lodged  at  the  ampulla 
of  Vater.  This  was  surmised  because  of  her  jaundice.  As  you  know, 
jaundice  is  produced  by  the  passage  of  bile  and  its  coloring  matter 
from  the  liver  into  the  lymphatic  vessels  and  the  blood.  Its  essential 
cause  is  obstruction  of  the  outflow  of  bile  into  the  intestines.  The 
obstruction  does  not  prevent  the  secretion  of  bile  by  the  liver,  hence 
there  is  a  consequent  dilatation  of  the  biliary  ducts  and  canals,  stagna- 
tion of  their  contents,  and  absorption  by  the  lymphatics  of  the  biliary 
coloring  matter  and  acids  which  reach  the  general  circulation  by  way 
of  the  thoracic  duct.  The  biliary  acids  have  the  power  of  destroying 
red  blood  cells,  thus  setting  free  hemoglobin — the  free  hemoglobin 
increases  the  formation  of  bilirubin  by  the  liver  and  so  may  serve  to 
intensify  the  jaundice.  The  characteristic  lemon-colored  appearance 
of  the  skin  and  conjunctiva  and  urine  are  noted  at  this  stage.  The 
feces  become  clay  colored,  owing  to  the  absence  of  coloring  matter, 
and  we  often  have  constipation  accompanying  these  cases,  with  alter- 
nating attacks  of  mucous  diarrhea,  as  a  prominent  symptom. 

We  will  now  open  the  gall  bladder,  and  we  find  many  small  stones 
floating  in  the  dark  colored  fluid.  These  are  removed  with  the  scoop. 
The  calculi  in  the  cystic  duct  are  easily  milked  up  into  the  gall  bladder 
and  removed.  Here  in  the  common  duct,  however,  is  quite  a  large 
stone  which  we  can  neither  push  upwards  nor  down  into  the  duodenum. 
I  am  unable  to  crush  the  stone  with  my  fingers — and  I  never  use  a 
forceps  for  that  purpose  lest  the  walls  of  the  duct  be  damaged  per- 
manently,— so  we  will  do  a  choledochotorhy ;  here  is  the  stone.  You 
will  note  the  free  discharge  of  bile  which  flows  into  our  laparotomy 
pads  and  which  we  will  continue  to  sponge  away  until  it  stops.  Two 
catgut  sutures  are  placed  through  the  edges  of  the  cut  into  the  com- 
mon duct,  and  passed  around  a  long,  dressed,  rubber  tube,  fenestrated 
at  its  lower  end.  These  sutures  will  hold  the  end  of  the  tube  in  place 
for  about  ten  days.  Two  heavy  strips  of  iodoform  gauze  are  placed 
on  either  side  of  this  tube,  and  will  be  left  in  place  several  days 
after  the  tube  is  removed.  The  gall  bladder  is  also  drained  with 
rubber  tubing,  and  the  abdomen  closed  in  the  usual  way. 

18 


Chronic  Appendicitis. 

This  is  a  case  of  chronic  appendicitis.  Our  patient  is  a  young 
girl  of  seventeen  years,  born  in  this  country.  For  the  last  year  she 
has  had  variable  symptoms,  paroxysmal  pains  being  the  most  constant ; 
these  were  confined  to  the  right  iliac  fossa.  Associated  with  this 
there  has  been  intestinal  indigestion,  alternating  with  mucous  diarrhea 
and  constipation.  The  patient  is  extremely  nervous — a  symptom  very 
prevalent  in  chronic  appendicitis. 

The  right  rectus  incision  is  the  one  we  will  use,  pulling  aside  the 
muscle  after  dividing  its  anterior  sheath,  and  incising  the  posterior 
sheath  and  peritoneum  which  leads  us  into  the  peritoneal  cavity.  With 
the  finger  we  endeavor  to  hook  up  the  cecum,  but  we  are  prevented 
from  doing  so,  with  the  freedom  we  usually  experience,  because  of 
the  adhesions.  We  find  the  appendix  somewhat  chronically  inflamed 
and  enclosed  in  a  well  formed  pocket.  Bands  running  from  the  ileum 
to  th-e  cecum  constitute  this ;  here  in  the  cecal  wall  I  find  a  hard 
mass  snugly  imbedded.  We  will  remove  this.  It  is,  as  you  see,  a 
calcified  body,  about  the  size  of  a  ten  cent  piece.  It  is  white  and  hard, 
and  may  be  a  calcified  gland  or  a  small  ruptured  blood  vessel  which 
has  undergone  calcification.  Perhaps  it  was  this  which  caused  the 
adhesions,  through  irritation  and  the  resultant  inflammation.  We  will 
send  the  specimen  to  the  laboratory  and  perhaps  the  pathologist  will 
be  able  to  help  us  out.  The  appendix  is  somewhat  thickened ;  we  will 
remove  it,  and  invert  the  stump  according  to  the  Dawbarn  method. 

Fracture  oe  Pelvis;  Rupture  of  Bladder. 

The  last  case  for  operation  today  is  this  small  boy  who  was 
brought  in  by  the  ambulance  this  morning.  He  is  twelve  years  old. 
Several  hours  ago,  he  climbed  upon  the  seat  of  an  automobile  truck 
while  the  driver  was  delivering  goods.  He  started  the  machine,  and 
then  becoming  frightened,  jumped  from  the  truck  and  fell  under  the 
wheels.  The  rear  wheel  passed  over  him,  causing  a  comminuted  frac- 
ture of  the  pelvis  and  rupture  of  the  bladder.  We  thought  that  he 
would  die,  soon  after  his  arrival  in  the  hospital,  from  shock,  but  he  is 
still  alive  and  has  some  pulse.  We  bring  him  to  the  operating  room 
because  it  is  impossible  to  pass  a  catheter  into  his  urethra,  and  because, 
as  you  see,  his  pernieum  is  bulging  to  an  alarming  extent  from  extra- 
vasated  urine.  We  will  make  a  single  incision  into  the  perineum,  and 
you  see  the  large  amount  of  bloody  urine  which  escapes.  We  believe 
this  to  be  a  humane  thing  to  do,  notwithstanding  the  fact  that  we  do 
not  believe  the  boy  will  live.  By  passing  the  finger  through  the  wound 
we  find  the  pubic  bone  torn  from  its  mooring,  and  lying  on  the  rectum. 
The  ileum  is  fractured  in  several  places.  We  will  do  nothing  further 
now,  except  to  place  a  drain  in  position  to  carry  ofif  the  extravasated 
urine.    We  must  await  developments. 


19 


THE  TREATMENT   OF   GALL-STONE   DISEASE. 
Mathias  Figueira,  M.D.,  F.A.C.S. 

Case  L  This  patient  came  to  the  hospital  with  the  history  of  stom- 
ach trouble  and  more  or  less  pain  for  a  number  of  years.  She 
remembers  suffering  severe  pains  at  intervals,  several  years  ago.  She 
had  no  severe  pain  lately  but  has  suffered  from  stomach  and  intestinal 
trouble  in  the  form  of  indigestion  and  constipation.  At  admission 
to  hospital  besides  the  above  symptoms  she  did  not  present  anything 
noticeable  except  a  quite  marked  tumor  under  the  right  costal  border 
moving  with  respiration  and  continuous  with  liver.  It  was  not  very 
tender  and  abdomen  did  not  show  any  marked  signs  except  moderate 
distension.  At  operation  the  tumor  was  found  to  be  caused  by  a 
very  much  enlarged  gall  bladder,  containing  fifteen  stones,  one  of 
them  as  large  as  a  pigeon's  egg.  It  weighed  130  grams.  The  length 
was  15  centimeters  and  the  greatest  width  6  centimeters.  The  walls 
were  5  millimeters  in  thickness.  On  section  it  showed  the  lesions  of 
chronic  inflammation.  Patient  made  a  good  recovery  and  is  now 
well. 

Case;  II.  The  second  case  I  report,  came  under  by  care  two  years 
ago.  A  young  woman  was  taken  with  abdominal  pain  that  soon 
centered  under  the  costal  border  on  right  side  and  required  hypo- 
dermic injections  of  morphine  for  relief.  After  pain  subsided  her 
stomach  was  so  irritable  that  rectal  alimentation  had  to  be  resorted 
to  for  several  days.  Under  the  most  careful  dieting  and  care  she 
recovered  but  was  soon  taken  with  a  similar  attack  and  that  followed 
by  another  at  such  close  intervals  in  spite  of  the  best  care  and  advice 
that  operation  had  to  be  done  to  save  her  from  grave  complications. 
She  is  now  well. 

Comment. — That  once  the  diagnosis  of  gall  stones  is  made,  opera- 
tion is  the  best  treatment,  all  surgeons  are  agreed.  The  internists, 
many  of  them,  still  claim  that  a  good  many  cases  of  gall  stones  can 
be  cured  by  medicine  and  proper  dietetic  treatment.  It  is  certainly 
possible  for  gall  stones  under  rare  conditions  to  pass  into  the  intes- 
tines and  be  eliminated  that  way,  and  anyone  who  has  seen  much  of 
gall  stone  disease  knows  that  under  medical  treatment  many  cases  will 
very  much  improve.  The  attacks  of  pain  will  disappear,  the  diges- 
tion will  improve,  the  appetite  return  and  such  patients  seem  to  re- 
cover and  remain  comparatively  well  for  months,  sometimes  for 
years,  and  the  doctor  who  treated  them  will  enter  them  in  his  records 
as  cures.  Months  or  years  afterward  when  the  patient  has  passed 
out  of  the  doctor's  memory,  probably  out  of  his  neighborhood,  as 
such  cases  often  do,  another  doctor  will  get  the  case  and  will  have 
to  operate  on  it  to  save  life. 

The  first  case  reported  in  this  paper  is  probably  such  a  case 
and  is  down  in  somebody's  book  as  a  cure  of  gall  stones  by  medicine. 

I  have  no  doubt  that  if  the  history  of  cases  that  come  to  the 
operating  table  with  such  grave  complications  as  adhesions,  per- 
foration, involvement  of  neighboring  organs,  stricture  of  duct — if  the 

20 


history  of  such  cases  were  carefully  traced,  the  history  of  gall  stones 
"cured"  by  medicine  would  be  elicited. 

Medical  treatment  bears  the  same  relation  to  these  cases  as  the 
ice  bag  does  to  complicated  appendicitis  cases. 

As  for  those  corresponding  to  the  second  case  here  reported, 
even  the  internists  will  admit  the  urgent  indication  for  surgical  inter- 
ference. 

It  is  very  important,  I  believe,  to  bear  in  mind  that  of  all  organs 
the  stomach  oftener  presents  symptoms  caused  by  disease  in  other 
parts,  and  the  gall  bladder,  in  many  cases  of  obscure  and  insistent 
stomach  trouble,  is  the  organ  at  fault.  Appendicitis  and  gastric  ulcer 
have  often  been  operated  upon  when  the  gall  bladder  was  affected 
and  gall  stones  were  the  cause  of  the  trouble. 

The  statement  of  Dr.  Mayo  of  Rochester  in  a  recent  publication 
that,  of  375  cases  of  gall  stone  disease  coming  to  his  clinic  for  opera- 
tion, 13  per  cent  had  been  previously  operated  upon  for  the  wrong 
disease,  should  be  a  warning  and  a  lesson  to  all  of  us.  And  the 
practice  of  exploring  the  gall  bladder  in  all  abdominal  operations 
is  a  wise  one  as  gall  stones  are  often  present  with  other  abdominal 
diseases. 

I  know  of  a  case  in  which  the  surgeon  operated  for  salpingitis  with 
abscess.  He  was  wise  enough  to  explore  the  gall  bladder  which  he 
found  was  full  of  gall  stones.  He  did  not  remove  them  as  the 
patient's  condition  did  not  permit,  but  afterward  informed  her  of  the 
condition.  Within  a  few  months  symptoms  of  gall  stones  developed 
and  he  operated  with  success  and  credit.  Had  he  neglected  to  examine 
the  gall  bladder  and  inform  his  patient  when  symptoms  of  gall  stone 
developed  afterward,  the  chances  are  he  would  have  been  accused  of 
operating  for  the  wrong  disease. 

When  the  diagnosis  of  gall  stone  disease  is  once  made  what 
operation  is  the  best  to  perform  ?  Keen's  Surgery,  the  latest  standard 
work,  published  only  a  few  years  ago,  contains  the  following  state- 
ment by  the  leading  surgeons  of  the  country  on  gall  bladder  surgery: 
"Cholecystostomy  we  consider  the  normal  operation  for  gall  stones." 
In  1,600  cases  of  gall  stones  reported  cholecystostomy  was  performed 
in  1,200  cases  (just  three-fourths  of  all  cases)  with  a  mortality  of 
less  than  2  per  cent. 

Since  the  above  statement  and  statistics  were  published  quite  a 
change  has  taken  place  in  the  practice  and  teaching  of  some  leading 
clinics  in  this  country,  and  cholecystectomy  is  now  considered  the 
best  operation  for  gall  stones  with  a  mortality  a  little  less  than 
cholecystostomy.  Statistics,  published  last  year  from  the  Mayo  Clinic 
at  Rochester,  show  a  total  of  763  operations  for  gall  stones.  Of  this 
number  589  were  cholecystectomies  and  74  cholecystostomies.  This 
is  a  complete  reversal  of  the  practice  and  results  of  a  few  years  before. 

There  is  no  doubt  that  the  above  results  can  only  be  attained  with 
the  unusual  skill  and  experience  of  the  surgeons  at  the  head  of  that 
clinic.  Cholecystectomy  requires  more  skill  in  its  technic  and  greater 
care  to  avoid  injury  to  the  bowel,  the  vessels  and  main  duct.  This  is 
the  statement  made  by  Dr.  Mayo  in  comparing  the  two  operations. 

I  believe  statistics  from  other  clinics  and  from  the  general  practice 
of  surgeons  will  give  different  figures  corresponding  rather  to  the 
figures  in  Keen's  Surgery.  The  statement  of  Crile,  that  the  cases 
of  cholecystostomy  that  came  back  to  the  surgeon  are  the  cases  in 

21 


which  the  gall  bladder  was  diseased  or  the  mucous  membrane  in- 
flamed or  the  cystic  duct  closed  or  some  other  lesion  present  besides 
the  gall  stones,  is  certainly  true. 

If  at  operation  the  gall  bladder  has  a  normal  appearance,  the 
mucous  membrane  is  not  markedly  altered,  the  bile  flows  freely  and 
looks  natural,  I  believe  cholecystostomy  is  the  best  operation  in  the 
hands  of  the  general  surgeon.  Maybe  it  does  not  speak  for  so  much 
surgical  skill  but  the  curing  of  disease  and  saving  of  life  is  the  main 
thing. 

When  on  the  other  hand  if  the  gall  bladder  is  changed  by  in- 
flammation or  disease,  when  the  mucous  membrane  is  altered  or 
degenerated,  when  there  is  empyema  or  obstruction  of  duct,  then 
cholecystectomy  is  the  operation  and  the  surgeon  not  equal  to  it 
should  pass  the  case  to  better  hands. 

There  are,  however,  cases  in  which  the  indications  are  not  so 
clear  and  distinct,  border  cases  as  it  were.  If  I  am  permitted  an 
opinion  I  would  say  that  in  general  surgical  practise,  with  the  skill 
of  the  general  surgeon  at  hand,  the  patient  should  be  given  the  benefit 
of  the  doubt  and  cholecystostomy  performed. 

If  perchance  he  should  be  one  of  the  cases  that  come  back  then 
cholecystectomy  can  be  done. 

Quoting  again  from  a  noted  surgeon,  "the  drainage  operation  may 
be  chosen  for  primary  safety  with  later  cholecystectomy  recom- 
mended as  a  probable  necessity  in  the  future,  a  two  stage  operation." 

I  will  conclude  by  saying  that  when  the  deep  sea  captains  follow 
such  opposite  routes,  it  behooves  the  skippers  of  smaller  craft  to 
sail  by  'the  dead  reckoning  of  judgment  and  prudence,  rather  than 
by  the  sun  and  stars. 


22 


Ill 

ST.  JOHN'S  HOSPITAL. 


SURGICAL  CLINIC  AT  ST.  JOHN'S  HOSPITAL. 

Warren  L.  Duffield,  M.D. 

Probable  Fracture  of  Base  oe  Skull,  Immediate  Decompression. 

Clinical  History. — A  male  60  years  of  age  was  brought  to  the 
hospital  about  midnight  with  the  history  of  having  been  struck  by  an 
automobile.  When  admitted  he  talked  in  an  irrational  manner,  was 
actively  delirious,  requiring  restraint,  and  his  pupils  were  said  to  have 
been  unequal.  When  seen  about  one-half  hour  later  he  was  in  a 
deep  coma  and  could  not  be  aroused. 

Examination  revealed  four  wounds  of  the  head  and  a  fractured 
nose.  One  wound  directly  over  the  sagittal  suture  was  incised  and 
a  small  portion  of  the  bone  had  been  gouged  away  but  there  was  no 
demonstrable  linear  fracture.  The  other  wounds  were  not  complicated 
by  any  traumatism  to  the  bone.  The  pupils  were  now  equal,  contracted 
and  slowly  responded  to  light;  the  pulse  was  90  and  of  good  quality. 
Slight  patellar  reflexes  could  be  elicited  after  some  effort.  There  was 
tonic  muscular  spasm  of  all  extremities  but  slightly  less  pronounced 
in  the  left  forearm.  During  the  course  of  the  examination  there  had 
been  no  active  movements  of  the  extremities.  Upon  exploring  the 
scalp  wounds  all  extremities  with  the  exception  of  the  left  arm  were 
moved  by  the  patient,  but  with  no  apparent  return  of  consciousness. 
Upon  further  examination  of  the  left  arm  it  was  found  to  be  flaccid 
with  the  exception  of  the  adductors  which  were  in  a  condition  of  tonic 
muscular  spasm.     A  right  temporal  decompression  was  decided  upon. 

Operation. — Without  any  anaesthesia  and  through  an  inverted 
U  incision  over  the  right  temporal  region  the  fibres  of  the  muscle 
were  separated  and  the  skull  opened  with  a  Hudson  drill  and  the 
opening  enlarged  with  rongeur.  There  was  no  bulging  of  the  dura  but 
upon  opening  it  cerebrospinal  fluid  escaped  in  large  quantity  and  with 
considerable  force.  At  first  the  fluid  was  perfectly  clear  but  as  it  con- 
tinued to  flow  it  became  markedly  blood  stained.  Up  to  the  time 
of  opening  the  dura  the  patient  had  been  quiescent  but  as  soon  as  the 
fluid  began  to  escape  he  commenced  to  talk  in  an  incoherent  manner 
and  began  moving  his  extremities.  The  brain  substance  was  dark  in 
color  but  there  was  no  tendency  to  hernia.  A  rubber  tissue  drain  was 
introduced  to  the  dura,  the  muscles  sutured  over  and  the  flap  accu- 
rately restored. 

Post-Operative  History. — The  average  pulse,  temperature  and 
respiration  for  several  days  were  respectively  100,  loi  1-5  and  30. 
His  blood-pressure  six  days  later  was  90  and  120;  and  twelve  days 
after  operation  no  and  135.  For  about  ten  days  there  was  an  active 
delirium  almost  every  night  and  a  mild  delirium  during  the  day, 
though  when  spoken  to  he  would  answer  in  a  rational  manner  and  as 
a  test  was  able  to  read  a  newspaper.    At  present  his  pulse  and  tem- 

25 


perature  are  normal  and  only  occasionally  is  he  slightly  irrational  at 
night.  All  bodily  functions  are  apparently  normal  and  there  is  no 
paralysis. 

Comments. — Dr.  William  Browning  made  an  examination  sev- 
eral days  after  the  operation  and  expressed  the  opinion  that  the 
delirium  was  due  to  an  old  and  chronic  alcoholism. 

It  is  of  course  an  open  question  whether  this  patient  would  not 
have  recovered  under  expectant  treatment  but  as  all  symptoms  of 
intracranial  injury  had  apparently  increased  during  the  first  hour 
and  a  half  of  observation  an  exploratory  craniotomy  was  decided 
upon  and  the  results  would  seem  to  justify  the  decision. 

Gastro-Enterostomy  for  Duodi;nai,  Ulce;r. 

Clinical  History. — The  patient  is  a  married  woman,  38  years  of 
age,  whose  family  history  is  negative  except  for  the  death  of  one 
sister  from  tuberculosis.  The  patient  had  an  attack  of  pneumonia 
seven  and  one-half  years  ago,  had  puerperal  peritonitis  eight  years 
ago,  and  has  given  birth  to  seven  children.  Twice  during  each  of 
the  past  six  years  she  has  had  attacks  of  profuse  hemoptysis  with 
severe  pain  in  the  epigastrium.  Her  most  severe  attack  was  in  Sep- 
tember, 1914,  when  in  the  course  of  two  weeks  she  had  fourteen 
hemorrhages. 

Her  present  illness  began  one  week  ago  and  during  that  time  she 
has  had  eight  hemorrhages  each  lasting  about  five  minutes.  Repeated 
doses  of  coagulose  were  given  by  her  physician,  Dr.  C.  B.  Cortright, 
to  control  the  bleeding,  as  at  this  time  she  would  not  consent  to 
operation.  Her  epigastric  pain  is  somewhat  relieved  by  vomiting. 
There  is  macroscopic  evidence  of  blood  in  the  stools.  She  is  the  sub- 
ject of  a  mild  pulmonary  tuberculosis,  though  at  present  tubercle 
bacilli  cannot  be  demonstrated  in  the  sputum.  In  May,  191 5,  she  was 
twice  operated  upon,  once  for  the  removal  of  a  diseased  ovary  and 
later  for  the  removal  of  the  appendix. 

Examination  is  practically  negative  except  for  a  small  point  of 
considerable  tenderness  in  the  epigastrium.  The  stomach  contents 
are  acid,  free  HCl  15,  combined  acid  27,  total  acidity  46.  No  lactic, 
acetic  nor  butyric  acid  present.  Maltose  and  pepsin  and  a  large 
amount  of  mucus  present.  Microscopically  a  trace  of  blood,  many 
fungi  and  many  starch  granules  can  be  found.  Her  blood  count  is 
red-cells  3,950,000;  leucocytes  6,800;  hemoglobin  90  per  cent,  and 
polymorphoneuclear  cells  69  per  cent.  Examination  of  feces  reveals 
a  small  amount  of  blood.  X-ray  plates  show  a  filling  defect  of  the 
pyloric  end  of  the  greater  curvature  and  the  duodenum  immobilized 
to  the  left  of  its  normal  position.  There  is  an  overlapping  of  the 
duodenum  and  pylorus  and  a  consequent  blurring  of  the  picture. 

Operation. — Through  a  vertical  right  rectus  incision  an  ulcer 
about  one  and  one-half  cm.  in  diameter  can  be  distinctly  palpated 
in  the  inferior  wall  of  the  duodeno-pyloric  junction  and  at  this  point 
there  are  numerous  thin  but  firm  adhesions.  The  duodenum  and 
pylorus  are  drawn  upward  and  to  the  right  by  thin  but  firm  perigastric 
adhesions  which  extend  downward  across  the  duodenum  and  pylorus. 
A  typical  Mayo  posterior  gastro-enterostomy  is  now  performed  with- 
out difficulty  except  for  posterior  perigastric  adhesions,  similar  to 
those  above  noted  and  which  require  division  before  the  stomach  wall 
can  be  drawn  through  the  meso-colon. 

26 


Comments. — After  the  abdomen  was  opened  and  before  perform- 
ing a  gastro-enterostomy  a  Finney  pyloroplasty  with  resection  of  the 
ulcer,  or  a  simple  resection  of  the  ulcer  followed  by  a  posterior  gastro- 
enterostomy were  both  considered  but  abandoned  because  of  the  im- 
mobility of  the  pylorus  due  to  the  perigastric  adhesions  which  would 
have  required  considerable  time  for  their  dissection.  With  the  patient's 
history  of  pulmonary  tuberculosis  it  was  considered  wisest  to  do  the 
simplest  and  quickest  operation  which  would  give  relief,  and  this 
seemed  to  be  a  posterior  gastro-enterostomy. 

Post-Operative  History. — For  seven  days  her  recovery  was  smooth 
and  uninterrupted  and  all  sutures  were  removed.  On  the  eighth  day 
vomiting  began  and  became  more  constant,  the  vomitus  consisting 
mainly  of  bile.  On  the  tenth  day  the  abdomen  was  again  opened 
and  the  second  operation  revealed  the  meso-colon  folded  on  itself  and 
firmly  adherent  over  the  anastomosis  producing  an  obstruction.  Fol- 
lowing the  second  operation  there  was  slight  and  diminishing  vomit- 
ing.   At  this  time  her  convalescence  is  well  established. 

Comments. — There  are  two  features  of  interest  in  this  case.  Be- 
fore operation  the  hemoptysis  had  been  so  pronounced  that  she  was 
quite  exsanguinated,  yet  seven  days  post-operative,  though  the  vomit- 
ing was  constant  and  persistent  for  about  forty-eight  hours,  there 
was  not  the  slightest  evidence  of  blood.  A  fair  assumption  would 
seem  to  be  that  the  ulcer  had  become  quite  firmly  healed  in  the' 
interval. 

The  second  point  of  interest  is  that  in  spite  of  a  very  easy  gastro- 
enterostomy, excepting  for  a  few  posterior  perigastric  adhesions,  and 
with  but  little  handling  of  the  intestines  very  dense  adhesions  were 
found  across  the  entire  meso-colon  on  the  tenth  day.  These  adhesions 
were  out  of  all  proportion  to  the  traumatism  inflicted  and  were  more 
extensive  and  greater  than  we  have  ever  seen  under  the  same  condi- 
tions. Can  it  be  that  the  repeated  doses  of  coagulose  had  increased 
the  viscosity  of  the  peritoneal  fluid  and  thus  favored  the  formation 
of  early  and  dense  adhesions? 

Stab  Wound  of  the  Abdomen  Involving  the  Liver,  Stomach  and 

Omentum. 

A  colored  boy  of  nineteen  was  brought  into  St.  John's  Hospital 
by  the  ambulance,  suffering  with  an  incised  wound  of  the  abdomen 
and  stating  that  about  one-half  hour  before  admission  he  had  been 
stabbed. 

Examination  reveals  a  well  developed  muscular  youth  with  an 
incised  wound  2  cm.  long  slightly  to  the  left  of  the  median  line  at  a 
point  midway  between  the  ensiform  and  the  umbilicus,  and  protruding 
from  the  wound  is  a  mass  of  omentum  2  cm.  wide  and  7  cm.  long. 
The  pulse  is  76,  regular  and  of  excellent  quality,  the  temperature  is 
normal  and  there  is  no  vomiting,  abdominal  rigidity  nor  complaint 
of  pain,  and  no  evidence  of  shock. 

Operation. — A  vertical  incision  is  made  2  cm.  to  the  right  of 
the  wound  and  reveals  an  incision  passing  through  the  edge  of  the 
liver.  The  liver  is  sutured  on  both  surfaces.  There  is  also  a  wound 
2  cm.  long  in  the  anterior  wall  of  the  stomach  through  which  gas  can 
be  seen  bubbling.  A  double  row  of  Lembert  sutures  are  here  intro- 
duced.   No  further  injury  can  be  detected  on  the  right  side  but  on  the 

27 


left  two  severed  omental  vessels  which  are  bleedjng  briskly  axe 
ligated.  The  base  of  the  protruding  omental  mass  is  now 
ligated  and  sectioned  within  the  abdomen,  a  cigarette  drain  introduced 
to  the  neighborhood  of  the  opening  into  the  stomach,  the  operative 
wound  closed  in  layers,  the  protruding  omentum  removed  and  a  small 
drain  superficially  introduced  into  the  stab  wound.  In  order  to  pre- 
vent all  further  infection  of  the  abdomen  the  protruding  omentum  was 
carefully  excluded  from  the  operative  field  before  beginning  the  opera- 
tion and  was  not  touched  until  after  the  laparotomy  wound  was 
closed. 

Post-Operative  History  and  Comments. — Following  operation 
there  was  no  vomiting,  fluids  by  mouth  being  withheld  for  forty-eight 
hours,  during  which  period  Murphy  drip  was  administered.  At  no 
time  was  there  evidence  of  peritonitis  and  the  drains  were  removed 
on  the  fourth  day.  A  satisfactory  and  prompt  recovery  was  made, 
and  the  patient  was  discharged  fourteen  days  from  the  receipt  of  the 
injury. 

This  case  serves  well  to  illustrate  the  absolute  necessity  of  ab- 
dominal exploration  in  all  cases  of  penetrating  or  suspected  penetrat- 
ing wounds  of  the  abdomen,  a  practice  which  is  or  should  be  universal. 
Assuming  that  there  had  been  no  protruding  omentum  one  might  have 
felt  almost  justified  in  awaiting  the  development  of  symptoms  for 
there  were  certainly  none  present  to  indicate  serious  injury.  To  have 
delayed,  with  actively  bleeding  omental  vessels  and  a  penetrating 
wound  of  the  stomach  wall,  would  have  been  to  have  waited  too  long. 

Acute  Intejstinai,  Obstruction  Due  to  Procidentia  Uteri. 

This  case  is  reported  because  of  its  apparent  rarity.  The  index 
of  the  first  sixty  volumes  of  the  Annals  of  Surgery  does  not  record 
a  case. 

Clinical  History. — A  Hebrew  woman  of  57  years  was  admitted  to 
the  hospital  and  the  only  history  that  could  be  obtained  was  that 
twenty-four  hours  previously  vomiting  had  begun  and  had  increased 
in  frequency  until  at  the  time  of  admission  it  was  constant. 

Examination  revealed  a  woman  who  appeared  very  much  older 
than  the  age  given.  She  was  very  poorly  nourished,  her  pulse  was 
weak  and  thready  and  the  abdomen  markedly  distended.  She  was 
constantly  vomiting  small  quantities  of  fluid  almost  black  in  color. 
Protruding  from  the  vulva  was  a  mass  under  considerable  tension 
which  consisted  of  uterus,  bladder  and  rectal  wall — a  complete  pro- 
cidentia uteri.  All  hernial  openings  were  carefully  examined  but 
nothing  abnormal  found. 

We  were  unable  to  determine  from  her  how  long  she  had  suflFered 
with  a  procidentia  or  whether  it  had  increased  in  size  or  had  changed 
in  consistency  coincident  with  the  onset  of  vomiting,  but  received  the 
impression  that  there  had  been  some  change  in  it  at  this  time. 

Feeling  that  the  cause  of  her  obstruction  was  a  strangulation 
of  bowel  in  the  everted  vagina,  but  not  being  able  to  exclude  other 
possible  causes,  it  was  decided  to  reduce  the  mass  and  wait  for  an 
hour,  as  her  condition  did  not  seem  to  warrant  any  greater  delay. 
She  was  placed  in  a  slightly  exaggerated  Sim's  position,  the  mass  re- 
duced without  great  difficulty  and  the  vagina  tamponed. 

One  hour  later,  the  vomiting  still  persisting,  her  abdomen  was 

28 


opened  through  a  right  rectus  incision.  Upon  passing  the  hand  down 
into  the  pelvis  a  large  mass  of  small  intestine  could  readily  be  dis- 
lodged. The  intestine  was  dilated  to  about  three  times  its  normal  size 
and  was  of  a  deep  bluish  color.  The  large  intestine  from  the  rectum 
back  to  the  cecum  was  thoroughly  but  quickly  inspected  and  found  to 
be  collapsed.  The  ileum  was  found  to  be  collapsed  back  to  a  point 
about  45cm.  from  the  cecum  and  at  this  point  there  were  no  definite 
signs  of  obstruction.  Proximal  to  this  point  the  intestine  was  found 
distended  and  congested  and  distal  to  it  collapsed  and  light  in  color. 
Upon  handling  the  bowel  the  fecal  current  passed  on  and  into  the 
cecum.  The  uterus  was  drawn  up  and  rapidly  fixed  to  the  anterior 
abdominal  wall  and  the  abdomen  closed  as  quickly  as  possible. 

It  was  doubtful  whether  she  would  live  through  the  operation; 
but  under  stimulation  the  operation  was  completed.  She  died  about 
five  hours  later. 

Though  no  definite  point  of  obstruction  was  demonstrable  it  is 
our  opinion  that  the  obstruction  was  due  to  the  gut  being  forced  into 
the  sac  formed  by  the  everted  vagina — a  form  of  intestinal  obstruc- 
tion which  we  have  not  seen  recorded. 


29 


IV 
THE  LONG  ISLAND  COLLEGE  HOSPITAL. 


CLINIC   AT   THE   LONG   ISLAND    COLLEGE   HOSPITAL, 

MAY  12,  1916. 

Wm.  B.  Brinsmade,  M.D.  and  James  Watt,  M.D. 

Inguinai,  He:rnia. 

THE  patient  is  a  man,  thirty-five  years  of  age,  who  three  months 
ago  first  noticed  pain  in  his  right  inguinal  region.  This  was 
not  brought  on  by  any  particular  muscular  effort,  although  his 
ordinary  vocation  is  one  that  entails  hard  work.  Since  its  inception 
the  pain  has  gradually  increased  and  is  now  fairly  constant.  Six 
weeks  ago  he  first  noticed  some  protrusion  in  the  painful  region.  This 
protrusion  has  gradually  increased  in  size,  is  now  a  constant  annoy- 
ance and  hinders  his  work. 

On  examination,  the  patient  standing,  a  protrusion  the  size  of  an 
egg  is  visible  emerging  from  the  inguinal  canal.  On  percussion  this 
tumor  gives  a  resonant  note  and  on  manipulation  disappears  within 
the  abdomen  with  a  gurgle.  The  history  and  results  of  the  examina- 
tion indicate  the  presence  of  a  complete  inguinal  hernia.  The  ques- 
tion arises  whether  such  a  case  is  one  for  which  an  operation  should 
be  done  or  not.  All  operations  are  operations  of  either  necessity  or 
election.  When  an  operation  is  necessary  a  considerable  risk  to  the 
patient  must  often  be  assumed  by  the  operator,  whereas  in  opera- 
tions of  election  a  surgeon  should  not  assume  any  risk  that  can  possi- 
bly be  avoided.  A  hernia  such  as  the  one  under  consideration  might 
be  held  in  place  by  a  truss,  but  a  truss  is  a  very  inconvenient  and 
troublesome  implement  to  wear,  if  one  is  to  earn  his  living  by  hard 
work.  We  know  also  that  a  truss  will  not  cure  such  a  hernia  as 
this,  and  notwithstanding  that  a  truss  may  suffice  to  retain  the  hernia 
under  ordinary  circumstances,  it  not  infrequently  happens  that  in 
spite  of  the  presence  of  a  truss  the  hernia  escapes  under  special  con- 
ditions of  exertion  and  is  strangulated,  the  very  presence  of  the  truss 
adding  to  the  dangers  of  strangulation.  In  this  particular  patient  the 
records  show  that  his  kidneys,  heart  and  lungs  are  all  in  good  condi- 
tion and  we  have  therefore  advised  an  operation,  since  in  more  than 
95  per  cent  of  the  cases  done  in  this  clinic  a  permanent  cure  has  been 
secured  by  operation. 

The  surgeon  has  at  times  been  called  upon  to  give  an  opinion 
as  to  whether  a  certain  hernia  was  caused  by  an  accident.  The 
teaching  in  this  clinic  is  that  there  must  be  two  causes  for  hernia ; 
first,  a  predisposition  by  way  of  weakness  in  the  abdominal  wall  and 
second,  increased  abdominal  pressure.  Without  both  these  factors 
at  work  it  is  doubtful  if  a  hernia  would  ever  occur. 

The  method  of  operating  adopted  by  us  is  that  known  as  the 
Bassini  operation ;  so  far  it  has  given  in  our  hands  perfect  satis- 
faction. In  m.ost  cases  the  person  has  but  little  ether,  he  seldom  vomits 
and  there  is  no  shock.     Our  rule  is  to  keep  these  cases  in  bed  for 

33 


eight  days.  Upon  the  ninth  day  he  is  allowed  to  sit  up  in  a  chair,  and 
thereafter  to  walk  around  as  strength  returns.  The  cases  are  dis- 
missed on  the  fourteenth  day  after  operation  with  definite  instruc- 
tion to  have  the  bowels  move  daily,  and  to  engage  only  in  moderate 
exercise ;  to  avoid  lifting  of  heavy  articles  for  six  weeks,  after  which 
time  they  are  permitted  to  take  up  their  former  method  of  living. 

Fracture  of  the  Patella. 

A  man  forty  years  old,  while  walking  in  the  street,  caught  his 
foot  against  an  obstacle  and,  in  an  effort  to  save  himself,  threw  his 
body  backward.    As  he  did  this  a  snapping  was  fell  in  his  right  knee; 
he  sank  to  the  ground  and  found  to  his  surprise  he  could  not  lift  his 
right  leg.     He  was  taken  home  and  an  evaporating  lotion  was  applied 
to  the  knee  for  two  days  when  he  was  sent  to  the  hospital.    When  ad- 
mitted the  right  knee  was  swollen  and  the  patella  was  found  to  be  the 
subject  of  a  transverse  fracture,  with  separation  of  the  two  fragments 
so  that  a  finger  could  be  placed  easily  between  the  two.     He  has  now 
been  three  days  in  the  hospital,  five  days  have  passed  since  the  occur- 
rence of  the  accident.     There  is  considerable  redness  and  swelling 
about  the  injured  knee,  and  it  is  evident  that  the  knee  joint  is  filled 
with   bloody   fluid.      What   is   the   best   thing   to   do    for   this   man? 
The   prime   necessity   is    for   him   to    get   back   to    his   work   with    a 
sound  limb  in  the  shortest  time  possible.     An  absolute  bony   union 
of  a  broken  patella  is  not  essential   to   excellent   function.     There- 
fore, if  operation  is  done  upon  this  man  simply  for  bony  union,  the 
operation  would  be  one  of  election  and  not  of  necessity.     The  patient 
is  advised  to  have  the  knee  joint  opened,  the  blood  removed,  and  the 
broken  and  lacerated  tissues  restored  to  their  normal  positions,  and 
we  feel  safe  in  promising  him  that  he  will  have  a  more  perfect  result 
in  a  shorter  period  of  time  by  such  procedure  than  by  waiting  for 
healing  to  take  place   without  operative  interference.     We   had   in- 
tended to  perform  this  operation  this  morning,  but  we  find  that  there 
is  still  present  much  evidence  of  reaction  in  the  tissues  with  consider- 
able infiltration  of  blood.     Realizing  that  the  knee  joint  is  the  largest 
joint  in  the  body,  and  that  the  slightest  infection  may  lead  to  the  loss 
of  the  joint,  or  even  of  the  leg,  we  think  it  better  to  postpone  surgical 
interference  until  the  tissues  are  restored  to  a  more  normal  condition. 
When  we  do  open  this  joint  with  a  curved  transverse  incision  we  shall 
find  that  not  only  the  patella  is  broken,  but  that  both  lateral  ligaments 
are  torn  well  down  on  either  side  of  the  joint.    We  wih  also  observe 
that  when  the  lacerations  of  the  lateral  ligaments  have  been  repaired, 
the  broken  fragments  of  the  patella  will  have  almost  restored  them- 
selves to  their  proper  position.    The  dense  fibrous  fascia,  covering  the 
anterior  surface  of  the  patella,  will  have  been  torn  across  and  its 
lacerated  edges  will  have  dropped  down  like  a  fringe  between  the 
fragments.     These  fibers  are  lifted  out  and  the  fascia  sutured  with 
a  few  fine  catgut  sutures.     After  the  operation  the  extended  leg  will 
be  put  in  a  plaster  case,  and  the  patient  confined  to  bed  for  seven 
days,  at  the  expiration  of  which  time  the  case  will  be  taken  off  and 
the  skin  sutures  removed.    A  lighter  case  is  then  applied  and  cut  into 
anterior  and  posterior  sections.     The  patient  is  allowed  to  get  out  of 
bed  and  sit  in  a  chair  for  the  next  five  days,  at  the  expiration  of  which 
time  the  case  is  left  off  while  the  patient  is  in  bed  and  reapplied  every 
time  he  gets  up.     After  eighteen  days  passive  motion  and  massage 

34 


are  practiced  and  the  patient  is  encouraged  to  bend  the  knee.  This 
method  of  treatment  is  kept  up  until  the  patient  is  able  to  flex  his 
knee  to  a  right  angle,  after  which  he  is  discharged  with  instructions 
to  carry  a  cane  in  the  streets  constantly  for  the  next  two  months. 
Such  care  and  help  is  important  to  avoid  dangers  of  refracture. 

The  functional  results  from  the  closed  method  of  treatment  are 
often  so  excellent  that  a  surgeon  is  not  justified  in  urging  an  opera- 
tion in  all  cases  of  fracture  of  the  patella.  Such  an  operation  should 
never  be  performed  except  under  the  most  rigid  asepsis.  In  this 
clinic  we  never  put  anything  into  a  wound  which  has  not  been  boiled ; 
the  operator  and  assistant  should  leave  an  operation  with  their  gloves 
as  clean  as  when  they  commenced ;  the  blood  clot  being  removed  with 
toothed  forceps  and  a  spoon  curette.  If  there  is  any  question  about 
the  desirability  of  doing  an  open  operation,  always  decide  in  the  nega- 
tive. One  should  be  perfectly  sure  that  the  tissues  have  a  normal 
amount  of  resistance,  and  that  the  surroundings  are  surgically  perfect. 
It  is  for  this  reason,  therefore,  that  operation  on  this  patient  is  post- 
poned until  a  future  date. 

Choi,e;cyste;ctomy  for  Chronic  Ini^lammatign  of  thf  Gai^i, 
Bladder  with  Gali,  Stonfs. 

The  patient  is  a  woman  forty-two  years  of  age  who  was  brought 
to  the  hospital  six  days  ago,  suffering  acutely  with  pain  in  the  upper 
right  quadrant  of  the  abdomen  and  over  a  small  area  in  the  back  close 
to  the  spine.  She  had  been  vomiting  for  two  days  and  had  a  tem- 
perature of  1023^  and  was  jaundiced.  During  the  past  six  years  she 
has  had  from  time  to  time  attacks  similar  to  the  present  one,  but 
never  so  severe.  She  has  had  two  pregnancies  during  this  period  and 
during  each  pregnancy  has  had  several  attacks  similar  to  the  first  one. 
There  was  bile  in  her  urine  and  her  stools  were  clay  colored.  She 
commenced  to  improve  as  soon  as  she  entered  the  hospital  and  her 
jaundice  has  almost  disappeared.  We  never  operate  upon  any  cases 
of  pronounced  jaundice  where  it  is  possible  to  postpone  operation. 
The  patient  describes  so-called  bilious  attacks  as  occurring  from  time 
to  time  and  not  associated,  in  her  mind  at  least,  with  the  ingestion 
of  or  abstinence  from  food.  She  is  a  well  developed  women  of  good 
frame.  It  is  fair  to  assume  an  obstruction  to  the  flow  of  bile.  I 
want  to  call  particular  attention  to  Boas'  sign  which  is  pain  over  a 
restricted  area  in  the  back,  directly  behind  the  region  of  the  gall 
bladder.  I  have  never  failed  to  find  stones  in  any  case  in  which  this 
symptom  was  distinctly  present,  but  on  the  other  hand  I  have  often 
found  stones  where  the  symptom  was  not  present.  With  such  a  his- 
tory and  condition  as  has  been  described  one  is  justified  in  urging 
an  operative  procedure  because  it  is  certain  that  she  will  never  be 
well  of  these  attacks  until  the  cause  is  removed,  and  that  she  may 
develop  conditions  which  might  become  rapidly  fatal.  Mere  pres- 
ence of  gall  stones  alone  does  not  demand  operation,  since  statistics 
show  that  in  a  large  percentage  of  all  adult  cadavers  gall  stones  are 
found. 

The  patient  has  accepted  our  advice  and  is  ready  for  operation. 
As  the  ciher  is  administered  it  is  noticeable  that  she  takes  it  well.  A 
pad  placed  under  her  back  brings  the  liver  well  to  the  front.  A  trans- 
verse incision  is  made  through  the  right  rectus  muscle,  about  I  inch 
below  the  border  of  the  ribs,  because  it  seems  to  give  a  wider  field 

35 


for  easy  operative  manipulation,  and  also  because  it  is  easier  to  close. 
I  do  not  know  who  first  suggested  this  incision,  but  I  saw  it  used  in 
Germany  many  times  several  years  ago,  and  more  recently  it  has  been 
brought  to  the  attention  of  American  surgeons  by  Dr.  Moschcowitz  of 
Mt.  Sinai  Hospital,  New  York.     After  the  abdomen  has  been  opened 
a  large  sheet  of  gum  rubber  is  placed  so  as  to  cover  the  exposed 
intestines,  and  on  this  rubber  the  gauze  sponges  that  are  used  are 
placed.     Thus  these  sporgcs  absorb  whatever  discharge  there  may  be 
without  coming  in  co'iiact  with  the  intestines.     I   believe   this   pro- 
cedure to  be  of  considerable  value  in  prevention  of  that  abomination 
of  abdominal  surgery,  adhesions.     The  region  having  been  oriented 
we  discover  a  small  gall  bladder  with  thickened  walls,  within  which 
just  as  it  narrows  down  to  the  cystic  duct  a  stone  can  be  felt.     The 
neck  of  the  gall  bladder  is  tightly  contracted  on  it  so  that  it  cannot 
be  pushed  up  into  the  fundus  of  the  gall  bladder.     The  entire  gall 
bladder  and  cystic  duct  are  hard  and  thickened.    Nothing  is  discovered 
in  the  common  duct  by  palpation.    We  have  then  to  deal  with  a  diseased 
gall  bladder  and  duct  containing  a  stone.     In  our  opinion  this  gall 
bladder   is   diseased   beyond   repair   and   must   be   removed.      If    left 
behind  and  drained  it  will  merely  become  a  foreign  body.     The  cystic 
duct  is  therefore  caught  in  a  right  angle  clamp,  by  blunt  dissection  the 
cystic  artery  is  separated  and  tied.     The  duct  is  then  cut  across  be- 
tween tv/o  clamps  and  the  gall  bladder  removed  from  behind  forwards, 
leaving  the  surface  of  the  liver  which  oozes  very  slightly.     A  long 
probe  is  then  passed  through  the  duct  into  the  common  duct  and  the 
ampulla  of  Vater  for  exploration.    No  obstruction  is  discovered.    The 
duct  is  then  ligated.     A  long  cigarette  drain  is  fastened  to  the  duct 
and  another  drain,  containing  a  split,  soft  rubber  catheter,  packed  with 
gauze,  is  placed  beside  it.     Notice  that  both  these  drains  are  covered 
with  gutta  percha  tissue  so  as  to  prevent  any  irritation  which  might 
set  up  adhesions.    All  sponges  are  now  removed  and  counted.     There 
is  no  moisture  at  the  bottom  of  the  wound  or  around  the  liver  so 
the  rubber  dam  is  removed. 

We  are  sure  that  this  woman  will  be  restored  to  her  family  in 
three  weeks  in  better  health  and  with  a  better  disposition  than  she 
has  had  for  a  long  time.  Whenever  you  find  either  a  man  or  woman 
who  is  cranky  and  disagreeable  to  live  with,  do  not  put  it  down  to 
disposition  or  cussedness  until  every  effort  has  been  used  to  find  a 
local  or  pathological  cause.  In  this  connection  I  Vv^ould  impress  upon 
you  once  more  the  necessity  of  arriving  at  a  diagnosis  first,  by  the 
history ;  next  by  examination ;  and  finally  as  an  addendum  to  these, 
the  use  of  the  laboratory.  Do  not  learn  to  depend  entirely  upon  the 
X-ray  for  diagnoses ;  valuable  as  it  is,  it  is  sometimes  deceptive  and 
sometimes  also  it  fails  to  reveal  the  condition  which  is  present. 


36 


ArtificiaIv  Anus. 

In  certain  cases  of  cancer  of  the  rectum  when  the  entire  rectum 
can  be  removed  by  the  combined  abdominal  and  either  perineal,  sacral 
or  vaginal  operation,  it  becomes  necessary  to  create  an  artificial  anus. 
The  comfort  and  effectiveness  of  the  new  opening  determines  the 
well-being  of  the  individual.  For  the  satisfactory  control  of  an  artifi- 
cial anus  we  have  found  that  the  following  method  gives  the  best 
results :  A  transverse  incision  is  made  above  the  pubes,  and  the 
sigmoid  isolated.  The  gut  is  then  cut  across  well  above  the  growth 
and  a  second  small  incision  is  then  made  through  the  skin  about  2^^ 
inches  above  the  transverse  incision  and  to  the  left  of  the  median  line. 
This  brings  the  opening  well  above  the  pubic  hairs.  By  blunt  dis- 
section through  the  fibres  of  the  rectus,  keeping  well  in  front  of  the 
peritoneum  a  passage  about  2^  inches  long  is  created  down  to  the 
transverse  incision.  The  proximal  cut  end  of  the  gut  is  drawn  through 
this  passage  and  fastened  to  the  peritoneum  at  this  point  of  entrance 
in  the  abdominal  wall  and  to  the  skin  at  its  exit.  The  operation  for 
the  removal  of  the  cancer  may  be  performed  at  this  or  subsequent 
sitting.  The  effect  of  this  procedure  is  to  create  a  loop  or  segment  in 
which  fecal  contents  may  collect  beyond  which  there  is  a  perpendicular 
passage  through  the  rectus  muscle  which  seems  to  compress  the  bowel 
and  control  its  contents  to  a  mild  degree.  I  have  used  this  method  six 
times,  and  my  friend.  Dr.  Fiske,  has  used  it  four  times,  and  the  re- 
sults have  been  satisfactory  in  all  these  cases,  both  to  ourselves  and 
to  the  patients. 

I  now  present  a  patient  who  is  the  subject  of  an  artificial  anus 
thus  made.  A  woman,  who  was  operated  upon  eighteen  months  ago 
on  account  of  a  growth  in  the  rectum.  The  operation  was  performed 
as  described.  The  after  course  was  hard  for  several  months  owing 
to  a  large  amount  of  tissue-sloughing  through  the  peritoneal  vaginal 
wound.  She  has  now  gained  weight  and  recovered  full  strength  and 
considers  herself  a  well  woman  again.  The  artificial  anus  functionates 
in  a  very  satisfactory  manner;  by  using  a  small  syringe  each  morning 
she  is  able  to  empty  her  bowel  of  the  fecal  contents.  It  takes  her 
about  one-half  hour  each  morning  to  perform  her  toilet  for  the  day. 
She  wears  no  cup  and  only  a  simple  compress  made  of  a  few  layers 
of  gauze  and  cotton,  which  is  pinned  to  her  undervest.  I  believe  this 
is  far  better  than  any  other  form  of  artificial  anus.  As  far  as  I 
know  this  particular  procedure  has  not  been  described.  I  have  re- 
served any  description  of  this  procedure  until  it  had  been  performed 
several  times,  and  am  now  glad  to  present  it  to  Dr.  Pilcher  on  the 
occasion  of  our  celebration  of  his  fifty  years  of  devotion  to  humanity 
and  science. 


37 


THE  DIAGNOSIS  OF  FRACTURE  OF  THE  NECK  OF  THE 

FEMUR. 

John  D.  Rushmore,  M.D. 

THE  following  remarks  apply  to  the  diagnosis  of  fracture  of  the 
narrow  part  of  the  neck  of  the  femur,  or  intra  capsular  fracture. 
In  the  large  majority  of  patients  with  suspected  fracture  of  the 
femoral  neck  the  diagnosis  is  not  difficult ;  in  a  few  cases  one  may  feel 
uncertain  whether  a  fracture  exists  or  not,  without  the  evidence  fur- 
nished by  a  satisfactory  skiagraph.  On  the  other  hand,  before  the  use 
of  the  x-ray,  cases  have  been  reported  as  fractures  when  a  post  mortem 
has  failed  to  show  the  fracture ;  and  even  experts  may  differ  in  the  in- 
terpretation of  a  clear  skiagraph,  as  to  whether  a  fracture  exists  or 
not.  And  inasmuch  as  the  x-ray  apparatus  cannot  be  used  in  a  large  per- 
centage of  cases,  for  various  reasons,  one  is  obliged  to  fall  back  on  the 
long  list  of  symptoms  that  are,  singly,  uncertain,  but  taken  in  their 
totality,  render  mistakes  in  diagnosis  very  exceptional. 

Considering  then  the  symptom  on  which  we  base  a  diagnosis  of 
fracture  of  the  neck  of  the  femur,  the  most  positive  evidence  for  or 
against  the  existence  of  a  fracture  is  furnished  by  a  good  skiagraph, 
when  it  can  be  obtained. 

Next  to  a  skiagraph  I  have  depended  on  a  symptom  or  sign  which 
is  as  evident  to  the  eye  as  Allis's  sign  is  to  the  touch. 

Place  one  end  of  a  tape  measure  over  the  anterior  superior  spine 
of  the  ilium  under  firm  pressure  of  the  finger  or  thumb ;  have  an  as- 
sistant draw,  by  traction  on  the  foot,  the  limb  downward  to  its  utmost 
length  without  inflicting  pain ;  place  the  taut  tape  where  it  comes  op- 
posite to  the  inner  malleolus  over  that  bony  point  under  firm  pressure 
with  the  thumb  of  the  other  hand,  and  then,  being  careful  that  the 
knee  of  the  patient  is  kept  rigid,  have  the  assistant  shove  the  unbent 
limb  forcibly  but  slowly  up  toward  the  pelvis,  and  if  there  is  relaxation 
of  the  taut  tape  visible  to  the  eye,  a  fracture  of  the  neck  of  the  femur 
exists.  If  the  same  procedure  is  used  on  the  opposite  limb  there  is  no 
relaxation  of  the  tape.  The  amount  of  relaxation  that  takes  place  will 
depend  upon  the  presence  or  absence  of  impaction.  This  sign  has 
nothing  to  do  with  mensuration ;  any  flexible  and  inelastic  material  can 
be  substituted  for  a  tape  measure ;  even  the  edge  of  the  sheet  covering 
the  patient  may  be  used;  it  is  as  useful  in  a  one-legged  man  as  a  two- 
legged  man ;  and  probably  could  be  employed  where  the  patient  had  lost 
the  leg  of  the  affected  limb.  It  can  be  used  in  every  case  of  suspected 
fracture  of  the  femoral  neck ;  and  it  is  not  necessary  that  pressure 
should  be  made  exactly  over  the  top  of  the  iliac  spine  or  exactly  over 
the  edge  of  the  inner  malleolus.  The  two  important  points  to  be  ob- 
served in  this  procedure  are  that  the  examiner  should  use  forcible  pres- 
sure over  the  two  bony  points,  and  that  the  patient's  knee  should  be 
kept  rigid.     At  the  same  time  the  assistant  should  make  the  utmost 

38 


justifiable  traction  downward  and  pressure  upward  during  the  manipu- 
lation. I  at  first  thought  that  the  relaxation  visible  in  the  tape  indicated 
that  the  fracture  was  ununited,  and  that  the  sign  would  be  of  little  or 
no  value  when  there  was  impaction ;  but  from  the  inspection  of  ski- 
agraphs which  seemed  to  show  impaction,  and  where  the  relaxation  of 
the  tape  was  evident,  I  am  led  to  think  impaction  does  not  lessen  the 
value  of  the  sign.  It  is  surprising  how  little  approximation  (less  than 
a  quarter  of  an  inch)  of  the  points  of  pressure  will  show  a  marked 
sagging  of  the  tape.  In  differentiating  a  fracture  from  a  dislocation  of 
the  hip  joint,  I  have  had  no  experience  in  the  use  of  the  above  sign.  I 
imagine  the  same  relaxation  occurs  as  in  a  fracture;  but  the  signs  of 
each  of  these  conditions  are  so  different  as  not  to  give  us  trouble  in 
differentiating  them.  At  the  bedside  the  question  is  almost  always 
whether  the  patient  is  suffering  from  a  fracture  or  not,  and  not  whether 
he  has  a  fracture  or  a  dislocation. 

Taking  up  the  question  of  the  value  of  mensuration  in  the 
diagnosis  of  this  fracture,  it  is  common  experience  that  two  surgeons 
will  not  only  differ  in  their  measurement,  but  each  one  may  obtain 
different  results  in  his  own  measurements,  even  though  he  has  the 
patient  lying  on  a  table  and  with  the  line  of  the  body  perfectly  straight. 
The  usual  reason  given  for  these  differences  is  doubtless  valid,  that 
while  the  inner  malleolus  is  easily  made  out,  the  anterior  spine  is  not 
a  spine,  and  it  is  difficult  or  sometimes  impossible  to  be  sure  that 
one  is  pressing  over  the  exact  centre  of  it.  More  important  still  is  the 
inequality  of  the  limbs  demonstrated  by  the  late  Dr.  A.  T.  Bristow  in  a 
very  careful  set  of  measurements  of  the  femora  and  humeri  (Transac- 
tions of  the  American  Surgical  Association,  Vol.  XXVII.  Page  429). 
These  measurements  confirm  the  conclusions  arrived  at  by  the  late 
Dr.  J.  S.  Wight  from  measurements  in  the  living  subject.  These  tables 
prove  that  an  inequality,  varying  from  1-8  to  i  3-8  inches  may  exist 
in  the  length  of  the  lower  extremities,  the  difference  not  depending  on 
any  previous  lesion  in  the  bones  or  limbs  measured.  This  asymmetry 
demonstrated  to  exist  in  such  a  large  percentage  of  persons  (78  per 
cent  in  femoral  lengths  according  to  Bristow's  figures)  makes  any  con- 
clusions as  to  shortening  in  suspected  fracture  of  the  neck  of  the 
femur,  based  on  measurements  from  the  anterior  superior  illiac  spine, 
a  source  of  error. 

It  is  interesting,  but  not  important,  in  this  connection,  to  note 
the  asymmetry  that  exists  in  other  parts  of  the  body — in  the  head  as 
shown  by  comparing  the  two  sides  of  hatters'  patterns  that  are  used 
in  the  custom-made  silk  hats ;  in  tailors'  measurements  for  custom-made 
clothes ;  in  shoemakers'  measurements  for  custom-made  shoes ;  and 
sometimes,  though  rarely,  in  comparing  the  two  sides  of  a  face  or  the 
length  of  fingers  in  the  two  hands. 

It  is,  however,  very  important,  in  using  the  anterior  superior  spine 
of  the  ilium  in  measuring  the  comparative  length  of  the  lower  ex- 
tremities of  a  patient  to  ascertain  if  there  is  or  is  not  an  asymmetry 
in  the  pelvis  similar  to  those  mentioned  above.  It  has  been  taken  for 
granted  that  in  using  the  anterior  spine  for  measurements  of  this  char- 
acter that  symmetry  of  the  pelvis  exists  in  spite  of  the  fact  that  de- 
formity of  the  pelvis  is  a  subject  that  the  obstetrician  has  been  lecturing 
on  for  more  years  than  the  oldest  of  us  have  lived.  This  deformity 
is  no  doubt  due  in  most  cases  to  rachitic  or  other  disease.  But  the 
other  instances  of  asymmetry  mentioned  suggests  that  there  may  be  a 

39 


pelvic  asymmetry  short  of  actual  deformity  that  would  make  the  an- 
terior superior  spine  of  the  ilium  an  unsafe  point  from  which  to  meas- 
ure the  comparative  length  of  the  lower  extremities. 

Just  here  it  may  be  mentioned  that  it  is  unsafe,  when  there  is  ap- 
parent shortening  in  suspected  fracture  to  draw  the  limb  downward 
sufficiently  to  have  the  malleoli  on  a  line.  The  downward  traction 
should  be  accompanied  by  actual  measurement  from  some  fixed 
point  on  the  anterior  spine,  otherwise  the  apparent  lengthening  of  the 
afifected  limb  may  be  due  to  tilting  of  the  pelvis,  unless  counter  ex- 
tension is  used  and  both  limbs  drawn  down  with  equal  extension.  To 
prove  whether  there  is  asymmetry  of  the  normal  pelvis,  set  a  normal 
pelvis  thoroughly  cleansed  of  soft  parts,  on  a  flat  surface,  the  pelvis 
resting  on  the  point  of  the  coccyx  and  the  tuberosities  of  the  ischium; 
lay  a  ruler  across  the  anterior  spines,  and  in  a  few  cases  the  distance 
between  the  ruler  and  the  surface  on  which  the  pelvis  rests  will  differ 
on  the  two  sides.  Lack  of  ante-mortem  knowledge  of  the  history  of 
the  patient  and  a  possible  inequality  of  the  tuberosities  render  uncertain 
any  inference  as  to  the  asymmetry  of  the  spine. 

A  better  method  is  furnished  by  cadavers  in  the  dissecting  room. 
Drive  a  pin  into  the  top  of  the  middle  of  the  sternum  through  a  tape 
measure  in  order  to  avoid  any  slipping  of  the  tape,  and  measure  the 
distance  from  this  point  to  the  anterior  superior  spines  of  the  ilium 
(and  this  can  be  exactly  located  in  a  cadaver)  ;  and  it  will  be  found  that 
the  distance  between  the  two  points  on  the  right  and  left  side  will  differ 
in  many  cases.  In  one  body  that  I  measured  it  amounted  to  a  half  inch. 
Lack  of  knowledge  of  ante-mortem  injury  or  disease,  in  spite  of  evi- 
dence to  the  contrary  in  the  cadaver,  holds  here  as  well  as  in  pelvic 
measurements.  The  best  and  most  reliable  evidence  is  furnished  at  the 
bedside,  in  living  patients  who  can  testify  to  any  ailment  or  injury  that 
might  render  the  same  measurements  as  in  the  cadaver  uncertain.  The 
anterior  spine  is  more  difficult  to  locate  with  exactness  in  the  living 
person  than  in  the  cadaver,  and  one  must  be  careful  in  the  fixation  of 
the  upper  end  of  the  tape  in  the  sternal  notch,  and  also  be  careful  to 
allow  for  differences  produced  by  respiration.  In  spite  of  these  causes 
of  uncertainty,  I  found  the  measurements  in  forty  patients  confirmed 
the  results  of  the  cadaver  measurements.  In  four  cases  the  difference 
in  the  measurements  was  one-half  inch  (the  maximum).  It  varied 
from  this  to  equality  in  length. 

There  is  still  a  possibility  that  there  may  be  an  asymmetry  in  the 
malleoli  of  which  I  have  no  measurements  to  show  whether  it  does  or 
does  not  exist.  With  reference  to  the  method  of  holding  the  upper 
end  of  the  tape  between  the  patient's  teeth,  it  may  be  said  that  it  im- 
plies the  teeth  to  hold  the  tape,  also  a  sterile  tape  before  use,  and  a  re- 
sterilization  before  employing  it  in  the  same  way  again.  If  mensura- 
tion is  employed  at  all — and  it  certainly  should  be — I  think  with  Dr. 
Bristow,  "that  the  measurement  taken  from -the  supra-sternal  notch  to 
the  plane  of  the  heel,  as  indicated  by  a  plane  surface  in  apposition 
therewith,  will  prove  to  be  a  method  least  open  to  error.  The  follow- 
ing precaution,  however,  must  be  adopted :  The  measurement  must 
be  made  at  the  same  period  of  respiration.  The  plane  surface  in  ap- 
position with  the  heel  must  be  parallel  in  each  case,  as  a  slight  inclina- 
tion in  either  direction  would  mean  an  error  in  the  measurements." 

The  method  employed  in  Dr.  Bristow's  bone  measurements — a 
modified  shoemaker's  rule— would  allow  one  to  neglect  the  respiration 
as  a  cause  of  error.    I  have  preferred,  however,  to  use  the  "relaxation" 

40 


sign  described  above,  as  it  enables  one  to  neglect  the  respiration,  asym- 
metry, mensuration,  and  even  pelvic  deformity  in  the  diagnosis. 

Outward  rotation  of  the  foot  is  a  well-known  and  often  a  striking 
symptom  of  fracture  usually  marked,  sometimes  excessive  and  at  times 
absent.  In  a  few  cases  inward  rotation  is  present  and  difficult  to  ex- 
plain. Limitation  of  voluntary  inward  rotation  of  the  outward  rotated 
foot  is  also  of  some  significance.  This  outward  rotation  of  the  foot  gets 
its  importance  only  as  associated  with  other  signs  of  fracture,  for  it  is 
well  known  that  it  exists  with  contusion  of  the  hip  at  times,  and  even 
when  there  is  no  question  of  fracture,  as  in  general  anaesthesia,  in 
natural  sleep,  in  debilitating  disease,  especially  where  the  knee  is  even 
slightly  flexed,  and  in  the  cadaver.  I  once  saw  it  in  an  old  lady  suffer- 
ing from  senile  dementia  who  fell  out  of  a  low  bed;  the  outward  rota- 
tion was  marked  with  no  other  signs  of  fracture  except  difficulty  in 
standing  for  a  few  days.  The  rotation  disappeared  promptly,  and  after 
a  few  weeks  the  patient  fell  out  of  the  other  side  of  the  bed  producing 
a  less  marked  outward  rotation  than  on  the  other  foot  and  with  some 
lameness  and  with  the  same  prompt  recovery  as  before. 

The  inability  to  lift  the  extended  leg  from  the  bed  is  a  very  marked 
symptom  in  almost  all  cases ;  and  some  authorities  have  gone  so  far 
as  to  advise,  even  when  other  symptoms  were  absent,  that  such  a 
patient  should  be  treated  as  a  case  of  fracture.  I  have  seen  certainly 
six  cases  where  this  symptom  alone  was  present  and  a  clear  skiagraph 
has  negatived  the  possibility  of  a  fracture.  One  case  recently  was  an 
elderly  female  who  fell  on  her  left  hip  and  who  presented  this  symptom 
of  fracture  alone.  The  skiagraph  showed  no  fracture.  At  the  same 
time  the  patient  sitting  on  the  edge  of  the  bed  had  good  though  not 
quite  normal  power  in  extending  the  leg  on  the  thigh  and  flexing  the 
thigh  on  the  abdomen.  Another  case  with  this  symptom,  beside  out- 
ward rotation  of  the  foot,  shortening  and  the  ability  to  have  the  limb 
lengthened  by  traction,  and  a  positive  skiagraph,  after  six  weeks' 
treatment  by  Buck's  extension,  could  lift  the  extended  leg  while  the 
other  symptoms  of  fracture  were  as  evident  as  when  she  entered  the 
hospital.  This  symptom  is  present  in  fracture  of  the  patella;  and  I 
have  seen  it  in  acute  synovitis  of  the  knee  joint,  explained  perhaps  in 
this  instance  by  the  patient's  timidity  or  fear  of  inflicting  pain  in  any 
effort  at  lifting  the  limb. 

More  importance  should  be  attached  to  Hennequin's  symptom 
than  is  usually  done.  The  tenseness  and  swelling  in  the  upper  part  of 
Scarpa's  space,  which  is  described  as  Hennequin's  symptom,  are  quite 
characteristic  of  a  fracture,  and  should  be  sought  for  in  all  cases.  This 
sign  is  accompanied  by  the  helpless  look  of  the  thigh  if  the  foot  is 
markedly  rotated.  In  a  few  cases  of  very  thin  patients  I  have  been 
confident  that  I  could  feel  the  deformity  produced  by  the  fracture  by 
pressing  deeply  into  the  upper  part  of  Scarpa's  space,  in  spite  of  the 
increased  tension. 

The  so-called  excursion  of  the  trochanter  is  an  unreliable  sign  at 
best,  especially  so  if  the  patient  is  not  under  a  general  anaesthetic. 

Excursion  of  the  anterior  part  of  the  foot  with  the  patient 
anaesthetized,  when  the  trochanter  is  seized  between  the  fingers  and 
thumb  and  forcibly  lifted  and  depressed  vertically,  is  of  more  value 
than  the  trochanteric  excursion.  Allis'  symptom  (relaxation  of  the 
fascia  lata)  has,  theoretically,  much  to  commend  it,  but  personally  I 
have  not  felt  sure  of  its  presence  iniless  there  were  more  than  the  usual 
amount  of  shortening.     I  may  make  the  same  statement  with  regard 

41 


to  use  of  Nelaton's  line  and  Bryant's  triangle,  as  I  have  had  difficulty  in 
being  certain  about  the  exact  position  of  the  top  of  the  trochanter. 
Tenderness  on  pressure  in  the  upper  part  of  Scarpa's  space,  tenderness 
on  pressure  from  behind  forward  at  the  suspected  seat  of  fracture  and 
pain  complained  of  when  a  short  stroke  is  made  over  the  trochanter 
are  signs  usually  present. 

Crepitus,  false  (or  new)  point  of  motion  and  deformity  which  are 
relied  upon  in  diagnosticating  fractures  of  the  long  bones  are  largely 
neglected  in  the  diagnosis  of  the  fracture  under  consideration,  partly 
from  an  unreasonable  fear  of  breaking  up  impaction  by  manipulating 
the  limb  to  elicit  crepitus  and  partly  on  account  of  the  impossibility  of 
recognizing  the  other  two  signs. 

The  age  of  the  patient  is  to  be  considered  in  fracture  of  the  neck 
of  the  femur.  A  large  proportion  of  these  fractures  occur  in  elderly 
persons  with  sometimes  very  slight  injury ;  and  yet  not  a  few  fractures 
occur  in  the  femoral  neck  of  children  although  they  are  not  disabled 
to  the  same  extent  as  old  persons. 

Let  me  in  closing  add  one  or  two  observations  that  seem  not  in- 
appropriate in  this  connection.  With  the  exact  knowledge  furnished 
by  a  clear  skiagraph  the  interne  of  a  hospital,  unless  he  is  on  his  guard, 
will  be  tempted  to  neglect  the  search  for  the  well  established  signs  and 
symptoms  on  which  reliance  for  so  many  years  has  been  placed  in 
making  a  diagnosis  of  fracture  of  the  neck  of  the  femur;  and  when 
he  has  finished  his  term  of  service,  and  gone  into  practice,  and  not 
having  the  facilities  for  the  taking  the  skiagraph,  he  will  feel  keenly 
the  lack  of  that  aid  and  realize  that  he  has  been  lax  in  the  use  of  other 
and  quite  reliable  methods  of  diagnosis.  And  on  the  other  hand  he 
will  feel  the  unreliability  of  not  a  few  of  these  signs  that  have  been 
depended  on  in  former  years.  For  instance,  a  malingerer  might  sue 
another  for  causing  a  fracture  of  the  neck  of  the  femur  and  assume, 
as  a  result  of  injury,  pain,  inability  to  stand  or  flex  the  thigh,  outward 
rotation  of  the  foot,  inability  to  lift  the  extended  limb  from  the  bed; 
and  the  surgeon  might  find  a  shortening  of  a  half  inch ;  and  if  he  could 
not  find  a  deformity  at  the  seat  of  fracture  or  a  false  or  new  point  of 
motion  and  feared  to  examine  for  crepitus  in  the  interest  of  the  patient, 
and  did  not,  or  could  not,  confirm  or  correct  his  diagnosis  by  a  ski- 
agraph, the  patient  would  be  treated  for  a  fracture  that  did  not  exist 
and  a  jury  might,  within  reason,  render  a  verdict  for  damages  to  which 
the  patient  was  not  entitled. 


42 


V 
THE  GERMAN  HOSPITAL  OF  BROOKLYN. 


ECHINOCOCCUS    CYST   OF   THE    LEFT   LOBE    OF   THE 

LIVER  DISCHARGING  INTO  THE  LEFT 

HEPATIC  DUCT. 

Russell  S.  Fowler,  M.D.,  F.A.C.S. 

Chief  Surgeon,  1st  Division,  German  Hospital  of  Brooklyn. 

Cases  of  echinococcus  cyst  involving  the  biliary  passages  upon 
which  operation  has  been  done  are  very  rare.  Cases  have  been  re- 
ported by  Duval,  Langenbuch,  Sasse,  Lejeuntel  (Alencon),  Borchard 
(Bean),  Page,  Rossi,  von  Ruber,  v.  Mosetig-Moorhof,  Korte  and 
Kehr. 

Rupture  of  such  cysts  into  the  biliary  passages  is  very  uncommon. 
Rupture  causes  sudden  blockage  of  the  common  duct  and  is  the 
occasion  of  very  severe  biliary  colic.  There  is  profound  collapse  and 
death  has  been  known  to  immediately  follow.  Frequently  the  block- 
age is  diagnosed  as  calculus  obstruction.  A  correct  diagnosis  is  only 
possible  if  echinococcus  elements  are  found  in  the  stool.  In  some 
cases  there  have  been  reported  recurring  colicky  attacks  and  inter- 
mittent common  duct  obstruction ;  this  occurs  when  the  communication 
between  the  cyst  and  bile  passages  is  small  and  closes  from  time  to 
time.  In  other  reported  cases  there  were  no  colicky  attacks  but  symp- 
toms of  cholangitis.  One  fatal  case  presented  the  appearance  of  acute 
yellow  atrophy  of  the  liver.  In  cases  in  which  the  cyst  does  not 
present  as  tumor  the  differential  diagnosis  is  between  liver  abscess, 
cholangitis  with  chronic  stone  or  tumor  blockage  of  the  common  duct; 
the  diagnosis  is  only  possible  when  cyst  elements  are  recognized  in  the 
feces. 

Occasionally  rupture  occurs  without  symptoms ;  then  also  the  con- 
dition can  only  be  recognized  by  the  appearance  of  echinococcic  ele- 
ments in  the  stools.  In  some  cases  there  has  been  rupture  into  the 
veins  of  the  liver  or  inferior  vena  cava  followed  by  the  carrying  of 
embolic  cyst  elements  to  the  heart  and  pulmonary  arteries  occasion- 
ing immediate  death.  The  usual  symptoms  of  rupture  of  an  echino- 
coccic cyst  into  the  biliary  passages  are  severe  pain,  chills  and  fever. 
The  obstruction  in  the  common  duct  accompanying  the  rupture  may  be 
by  impaction  of  cyst  contents  or  by  inflammatory  swelling  caused  by 
the  intense  irritation. 

The  case  herewith  presented  gave  the  following  history:  N.  R., 
female,  age  21,  married.  No.  33205,  seen  in  consultation  with  Dr. 
Calogero  Giovinco  Nov.  12,  191 5.  About  four  months  before  the 
patient  had  noticed  that  her  urine  was  high  colored  and  she  became 
jaundiced;  after  three  days  this  jaundice  disappeared.  Two  weeks 
ago  she  had  pain  in  the  epigastrium,  diarrhea  and  vomiting.  This 
pain  continued  and  she  vomiteid  from  time  to  time.  Examination 
showed  the  abdomen  extremely  tender  below  the  right  costal  border 
and  over  the  right  lobe  of  the  liver.  There  was  rigidity  of  the  right 
rectus  muscle.     Moderate  jaundice. 

45 


Immediate  operation  was  done.  The  liver  was  found  enlarged 
and  acutely  congested;  the  edges  rounded.  Intense  inflammation  of 
gall  bladder  and  ducts  with  all  the  glands  along  the  cystic,  hepatic 
and  common  ducts  acutely  enlarged.  Locally  intense  peritonitis.  Gall 
bladder  opened  and  found  packed  with  fine  brilliant  yellow  sand. 
Walls  thickened  and  acutely  inflamed.  Gall  bladder  cleansed.  Chole- 
cystostomy.  Two  split  tube  drains.  It  was  not  thought  wise  to  ex- 
plore the  ducts  on  account  of  the  extreme  and  unusual  acute  inflam- 
mation. It  was  thought  in  all  probability  the  same  yellow  sand  would 
be  found  throughout  the  ducts  and  that  it  would  be  impossible  to 
cleanse  the  ducts  with  the  existing  inflammation. 

After  course:  The  jaundice  slowly  subsided  Dut  never  entirely 
disappeared,  a  little  yellow  tinge  persisting  in  the  eyes.  Pain  sub- 
sided. Bile  flowed  from  the  tube  and  appeared  in  the  feces.  It  was 
deemed  advisable  to  continue  gall  bladder  drainage  for  a  consider- 
able period  but  unfortunately  the  tube  became  displaced  on  the  tenth 
day  and  this  fact  was  not  discovered  until  the  day  following.  An 
attempt  to  replace  the  tube  was  unsuccessful.  The  patient  continued 
free  from  pain  except  slight  epigastric  cramps  from  time  to  time; 
gradually  gained  strength  though  a  slight  degree  of  jaundice  per- 
sisted. The  wound  healed  slowly.  There  was  but  slight  discharge 
of  bile  from  the  wound. 

Dec.  8,  191 5.    Discharged.    Wound  healed.    Very  slight  jaundice. 

Dec.  22.    Severe  epigastric  cramps  and  slight  increase  in  jaundice. 

Deo.  26.  More  severe  cramps  and  pain  over  the  gall  bladder 
and  liver.  Readmitted  to  hospital.  Slight  jaundice.  Liver  enlarged, 
two  fingers  breadth  below  free  border  of  ribs.  Gall  bladder  region 
sensitive.  Wound  firmly  healed.  Operation  was  delayed  on  account 
of  the  difficulty  which  it  was  felt  would  be  experienced  in  cleansing 
the  ducts.  However,  pain  increased  and  jaundice  deepened  slightly 
so  that  operation  could  no  longer  be  delayed. 

Operation.  Jan.  6,  1916.  Incision  through  previous  scar.  Many 
dense  adhesions.  Gall  bladder  adherent  to  scar;  acutely  distended; 
opened.  Contents,  thin  bile ;  mucous  membrane  intensely  congested ; 
hour  glass  type  of  gall  bladder.  Colon,  omentum,  duodenum,  liver 
and  stomach  densely  adherent  to  gall  bladder  and  neighborhood. 
Adhesions  separated  carefully  and  normal  anatomical  relationship  of 
parts  restored.  Cystic  duct  dilated  to  twice  normal.  Common  duct 
dilated  to  the  size  of  the  duodenum  or  even  larger.  Bile  aspirated 
from  common  duct  by  suction  apparatus.  Duct  incised,  walls  two  to 
three  times  normal  thickness ;  escape  of  bile  and  bile  stained  mem- 
branous detritus.  This  membranous  detritus  varied  in  size  from  pin 
point  to  the  size  of  the  last  joint  of  the  ring  finger.  Metal  catheter  in- 
troduced into  common  duct  and  duct  washed  out  with  saline,  the 
opening  into  the  duct  having  been  enlarged  sufficiently  to  permit  of 
the  ready  escape  of  the  saline  alongside  the  catheter.  Over  a  pint  of 
detritus,  stringy,  glutinous,  stained  black  with  bile,  was  washed  out 
in  this  manner  or  removed  by  a  long  curved  blunt  curet  introduced 
for  several  inches,  ten  inches  at  times,  into  what  was  taken  to  be  the 
left  hepatic  duct.  In  the  detritus  were  numerous  pieces  of  thick  green 
membrane,  recognizable  as  probable  echinococcus  cyst  lining.  Two 
gallons  of  saline  were  used.  A  large  probe  passed  freely  into  the  dun- 
denum. 

Some  saline,  about  a  pint  in  all,  was  allowed  to  run  into  the  duo- 
denum from  time  to  time.     When  the  saline  from  the  duct  returned 

46 


clear  the  curet  was  passed  up  and  fresh  membrane  removed  and  the 
flow  again  started.  This  was  repeated  until  so  far  as  could  be  as- 
certained the  ducts  were  clean.  The  curet  passed  ten  inches  into  the 
left  hepatic  duct  without  meeting  resistance.  There  was  no  bleeding 
from  the  irrigation.  Digital  exploration  revealed  a  large  opening  of 
the  common  bile  duct  into  the  duodenum,  an  opening  large  enough  to 
admit  the  tip  of  the  finger  into  the  duodenum;  the  common  duct 
itself  was  enormous,  the  finger  was  lost  in  it ;  toward  the  liver  the 
finger  felt  an  opening  about  twice  the  normal  size,  taken  to  be  the 
right  hepatic  duct  opening  and  a  continuation  of  the  common  duct 
taken  to  be  the  left  hepatic  duct  which  freely  admitted  the  finger. 
The  latter  was  fully  as  large  as  the  enlarged  common  duct,  the  size 
of  the  duodenum  (Fig.  i.) 

The  cystic  duct  opening  could  be  demonstrated  and  was  twice 
the  normal  size.  The  lining  of  the  common  duct  and  the  left  hepatic 
duct  was  smooth.  The  lining  of  the  common  duct  so  far  as  could  be 
seen  presented  no  evidence  of  inflammation.  The  patient  was  thin, 
worn  out  by  long  illness  and  bore  the  operation  very  badly.  The 
pulse,  while  the  beats  were  distinct,  was  extremely  rapid,  rising  to 
over  200  per  minute  during  the  irrigation  of  the  hepatic  duct.  It 
was  felt,  however,  that  the  patient  stood  very  little  chance  of  recovery 
unless  this  duct  could  be  freed  entirely  of  its  impacted  detritus.  When 
the  ducts  were  apparently  clean  and  the  irrigation  discontinued,  the 
pulse  fell  to  180  but  of  very  poor  quality.  Continuous  hypodermic 
whiskey  stimulation  was  given  from  the  time  the  pulse  became  weak 
and  saline  and  whiskey  were  administered  by  rectum.  A  rubber  tube, 
with  a  fenestrum  cut  in  the  side  was  placed  in  the  left  hepatic  duct 
through  the  common  duct  incision  in  such  a  manner  as  to  place  the 
fenestrum  facing  toward  the  duodenum.  This  was  used  to  take  the 
place  of  a  T  tube  which  was  not  available.  A  large  calibre  tube  was 
used  not  only  for  the  purpose  of  freer  drainage  and  to  avoid  block- 
age but  also  with  the  idea  of  allowing  of  irrigation  of  the  hepatic 
duct  and  common  duct  should  blockage  occur,  or  should  some  of  the 
detritus  show  in  the  discharge  from  the  tube.  The  incision  in  the 
duct  was  sutured  around  and  to  the  tube.  A  split  tube  was  placed 
in  the  foramen  of  Winslow ;  a  second  split  tube  in  relation  to  the 
junction  of  the  cystic  duct  with  the  common  duct  (which  juncture  was 
higher  than  usual)  ;  a  rubber  tube  was  placed  in  the  gall  bladder  and 
the  gall  bladder  edge  inverted.  The  condition  of  the  patient  did  not 
allow  of  cholecystectomy  although  otherwise  this  was  indicated.  A 
rapid  layer  closure  of  the  abdomen  was  effected.  The  patient  left 
the  table  with  a  pulse  of  180,  very  weak. 

After-course:  General  treatment  of  shock  (heat,  posture  and 
saline  by  rectum)  in  addition  to  direct  cardiac  stimulation  with  half 
strength  whiskey  by  hypodermic,  continuous  at  first,  then  every  two 
minutes,  later  every  five  minutes  and  so  gradually  stopped,  succeeded 
in  accomplishing  restoration  to  a  fairly  good  condition  in  twelve 
hours;  at  the  end  of  twenty-four  hours  the  bed  was  leveled  and  the 
patient  out  of  danger  so  far  as  the  operative  procedure  was  concerned. 
The  jaundice  was  less  marked.  At  no  time  had  it  been  severe.  For 
the  first  forty-eight  hours  the  discharge  through  the  duct  tube  con- 
nected with  a  subaqueous  drain  was  free  and  consisted  of  clear  bile. 

Jan.  8,  1916.  Detritus  began  to  pass  through  the  duct  tube  and 
it  was  feared  that  blockage  might  take  place.  Eight  ounces  of  saline 
were  slowly  introduced  into  the  common  duct,  the  subaqueous  drain 

47 


being  also  disconnected  and  cleaned.  The  introduction  of  saline  pro- 
duced no  pain.  The  patient  noticed  a  sensation  of  warmth  in  the 
epigastrium.  There  was  a  return  of  about  one  ounce  of  saline  through 
the  gall  bladder  tube.  The  return  flow  through  the  duct  tube  con- 
tained mucus  and  thick  stringy  material,  blood  streaked.  About  two 
ounces  of  the  saline  was  not  returned.  Following  this  flushing  of 
the  common  and  hepatic  ducts  the  discharge  from  the  duct  tube  again 
became  free  and  clear  bile.  As  much  as  ten  ounces  of  bile  was  col- 
lected in  the  bottle  in  twelve  hours. 

Jan.  9,  1916.  The  flushing  was  repeated  there  having  appeared 
some  detritus  in  the  discharge.  This  detritus  consisted  of  echino- 
coccus  cyst  lining.  At  this  irrigation  seven  ounces  of  saline  was  used, 
two  ounces  at  a  time  being  slowly  introduced  and  then  a  wait  of  a 
few  minutes.  The  return  flow  again  contained  mucus  and  thick, 
stringy  reddish  material.  About  two  ounces  of  saline  returned  through 
the  gall  bladder  tube.  Practically  all  of  the  saline  returned.  The 
patient  complained  of  slight  pain  during  the  irrigation. 

Jan.  10.  The  common  duct  was  irrigated,  seven  ounces  of 
saline  being  used.  Return  flow  as  before ;  two  ounces  were  returned 
through  the  gall  bladder  tube.     Practically  all  the  saline  returned. 

Jan.  II.  Common  duct  irrigated;  return  flow  about  the  same; 
some  saline,  about  two  ounces,  returned  through  the  gall  bladder  tube. 
Patient  noticed  scarcely  any  pain.  A  small  amount  of  saline  escaped 
through  the  wound  alongside  the  tubes. 

Jan.  12.  Return  flow  the  same.  Saline  returned  through  the 
gall  bladder  tube  and  a  considerable  amount  escaped  through  the 
wound  alongside  the  tubes.    This  irrigation  occasioned  no  pain. 

Jan.  13.  Sutures  removed ;  good  wound  union  except  at  emer- 
gence of  tubes.    Split  tube  removed. 

From  this  time  on  the  patient  was  comfortable.  Free  biliary 
drainage  continued  from  the  gall  bladder  tube  and  from  the  duct  tube. 
The  tubes  were  removed  on  the  seventeenth  day.  Further  convales- 
cence uneventful.  The  wound  discharged  a  good  quality  of  bile  and 
the  stools  became  normal. 

Feb.  5.  Discharged.  Wound  reduced  to  a  small  sinus.  No 
biliary  discharge.     Patient  strong. 

Pathological  Examination :  The  detritus  removed  at  operation 
showed  everywhere  echinococcus  cyst  wall  and  hooldets.  No  daughter 
cysts  could  be  demonstrated.  Examination  of  the  detritus  passed 
through  the  common  duct  tube  post-operatively  showed  characteristic 
booklets.  Repeated  examination  of  the  stools  failed  to  show  echino- 
coccus elements. 

Feb.  23.  Wound  firmly  healed.  Patient  has  remained  free  from 
symptoms  and  is  rapidly  regaining  her  strength. 

May  21.     Patient  has  remained  well. 


48 


EXTENSIVE   AND    RECURRENT    CARCINOMA    OF   THE 
BREAST  AXILLA,  NECK  AND  THORAX. 

James  Peter  Warbasse,  M.D., 

CASES  of  carcinoma  of  the  breast,  which  have  or  have  not  been 
operated  upon,  which  show  symptoms  of  extension  along  the 
course  of  the  axillary  vessels  and  nerves,  giving  rise  to  swelling, 
pain,  and  numbness  in  the  arm,  have  customarily  been  regarded  as  in- 
operable, and  condemned  to  morphine,  x-rays,  serums,  bacterins,  or 
quackery  until  the  inevitable  end.  The  suffering  of  these  patients  is 
very  great,  and  death  is  welcomed  as  a  rehef.  Has  surgery  nothing 
to  offer  these  unfortunates?  I  think  it  has.  The  mistake  made  by 
the  older  surgeons  has  been  to  think  of  carcinoma  of  the  breast  as 
carcinoma  of  the  breast,  when  as  a  matter  of  fact  it  soon  is  carcinoma 
of  the  axilla,  neck,  and  thorax,  and  should  be  thought  of  from  the 
beginning,  either  in  fact  or  potentially,  as  such. 

In  these  desperate  cases  the  surgeon  must  put  out  of  his  mind 
the  idea  that  he  is  considering  a  disease  of  the  breast,  lest  the  psychol- 
ogy of  timidity  be  stimulated  by  the  observation  of  the  great  distance 
from  its  origin  which  the  disease  has  traversed.  When  vs^e  think  of 
disease  of  the  axillary  vessels,  brachial  plexus,  scapula,  humerus,  clavi- 
cle, lymphatics  of  the  neck,  ribs,  pleurae  or  lungs,  we  are  aware 
that  any  of  these  structures  may  be  removed,  and  are  every  day  being 
attacked  with  impunity  by  surgery.  Primary  cancer  of  these  struc- 
tures is  unhesitatingly  extirpated.  Why  should  the  surgeon  withhold 
his  skill  from  such  disease,  if  perchance  it  were  preceded  by  a  can- 
cer of  the  breast? 

These  patients  can  be  made  more  comJortable,  and  life  in  a  cer- 
tain number  prolonged,  and  in  some  the  disease  cured  by  such  radi- 
cal operations.  I  have  no  hesitation  in  saying  that  such  operations 
have  more  to  offer  and  will  show  more  cures,  than  the  simple  am- 
putation of  the  breast  for  primary  carcinoma  which  was  commonly 
practiced  thirty  or  forty  years  ago. 

When  the  disease  involves  the  axillary  vessels  and  nerves  and  has 
palsied  the  arm,  the  operation  begins  with  amputation  of  the  shoulder. 
A  flap  is  made  from  such  tissues  as  are  farthest  from  the  disease.  The 
scapula  and  clavicle  should  be  removed  without  hesitation  in  order  to 
remove  disease  or  to  uncover  the  vessels  and  nerves  which  are  involved. 
The  axillary  and  sub-clavian  vessels  should  be  followed  up  into  the 
neck  and  thorax,  and  the  vessels  together  with  all  surrounding  tissues 
removed.  This  dissection  and  excision  may  be  carried  as  far  as  is 
necessary  to  reach  the  limit  of  the  disease.  At  the  same  time  the 
cords  of  the  brachial  plexus  should  be  followed  up  and  removed  with 
their  surrounding  tissues.  Before  cutting  the  nerve-trunks  they  should 
be  injected  with  novocain  to  block  impulses  and  prevent  shock. 

49 


This  dissection  and  excision  of  vessels  and  nerves  may  be  carried 
as  far  as  is  necessary.  If  it  is  discovered  that  a  rib  or  ribs  are  in- 
volved in  the  disease,  they  may  be  removed.  Ribs  are  removed  for 
other  conditions;  why  not  to  save  a  patient  from  cancer?  Involve- 
ment of  the  pleura  calls  for  resection.  Involvement  of  the  lung  de- 
mands removal  at  least  of  the  affected  lobe.  A  lobe  or  the  whole  lung 
is  excised  for  other  disease,  why  not  for  carcinoma . 

There  is  no  structure  in  the  side  of  the  neck  which  may  not  be 
sacrificed.  Vessels,  including  the  internal  juglar  and  carotids,  may 
be  resected.  The  brachial  plexus,  vagus,  and  phrenic  nerves  may  all  be 
removed.  In  the  chest  the  only  structures  which  must  be  preserved  on 
one  side  are  the  heart,  aorta,  and  vena  cava.  The  whole  of  one  lung, 
the  ribs  which  cover  it,  clavicle,  scapula,  arm,  all  the  vessels  and  nerves 
of  one  side  of  the  neck,  and  the  neighboring  and  involved  connective 
tissue,  muscles,  and  lymphatics  may  be  extirpated.  This  means  that 
everything,  practically  on  one  or  the  other  side  of  the  spinal  column 
from  the  base  of  the  skull  to  the  diaphragm  may  be  removed  (Figs,  i 
and  2). 

No  operation,  of  course,  would  involve  all  of  these  structures;  can- 
cer would  not  involve  them  all.  They  are  enumerated,  however,  to 
show  the  possibilities  of  radical  operations.  Such  procedures  should  be 
carried  out  with  due  regard  for  the  possibilities  of  shock.  Blood  should 
be  saved;  and  nerve  trunks  should  be  desensitized.  Operations 
of  this  sort  may  be  done  in  several  stages,  with  intervals  of  several  days 
for  recuperation.  In  the  hands  of  the  experienced  surgeon  who  knows 
how  to  save  blood  and  minimize  shock,  these  operations  have  much 
to  offer. 

The  experience  of  surgeons  is  showing  that  many  patients,  other- 
wise doomed  to  a  painful  exodus,  may  be  made  comfortable,  may 
have  life  prolonged,  or  may  be  cured  by  such  radical  procedures.  The 
literature  of  surgery  is  growing  rich  in  the  reports  of  these  triumphs. 
Presumedly  hopeless  cases  have  been  cured.  Many  cases  have  been 
operated  upon  repeatedly  for  recurrences  and  life  prolonged,  or  the 
disease  ultimately  cured.  No  patient  should  be  regarded  as  beyond  the 
hope  of  relief  unless  the  general  toxemia  and  inanition  indicate  an 
early  conclusion. 


50 


™      nS 


EPITHELIOMA  OF  NOSE. 
James  Peter  Warbasse,  M.D. 

THIS  patient,  a  man  now  seventy-two  years  of  age,  was  operated 
upon  by  me  twenty-two  years  ago  for  epithelioma  of  the  nose. 
At  the  place  where  the  nose-clip  of  his  eye-glasses  pressed 
against  the  skin  on  the  side  of  the  nose,  an  indurated  area  had  de- 
veloped. Discontinuation  of  the  pressure  by  changing  the  position  of 
the  clip  and  modifying  the  character  of  the  glasses  was  not  followed 
by  healing.  The  area  was  small,  and  the  induration  but  slight,  still 
the  suspicion  of  epithelioma  was  sufi&cient  to  call  for  its  removal.  Ac- 
cordingly, under  cocaine  anaesthesia,  an  eliptical  incision  was  made 
about  the  area  of  the  disease,  which  was  removed,  together  with  a 
small  zone  of  apparently  normal  skin  around  it.  As  large  a  wound  was 
made  as  could  be  closed  by  simple  suturing.  The  closure  of  the  wound 
was  accomplished  by  interrupted  silk  sutures.  The  removed  piece  was 
subjected  to  microscopic  examination  by  Dr.  Eugene  Hodenpyle  and 
Professor  T.  Mitchell  Prudden,  of  the  College  of  Physicians  and  Sur- 
geons, New  York,  both  of  whom  reported  that  the  growth  was  epi- 
thelioma. Most  probably  enough  tissue  had  been  removed  to  eradi- 
cate the  growth.  The  incision  had  been  placed  about  2  m.  m.  away  from 
the  apparent  disease.  Still  the  operation  had  been  done  for  two  pur- 
poses: (i)  diagnosis  and  (2)  therapy.  Had  a  positive  diagnosis  of 
epithelioma  been  made  before  the  operation,  the  therapy  would  have 
been  expressed  in  a  wider  operation. 


Plastic  on  Nose 

(a)  The  lines  of 
skin  incision. 

(b)  Tumor  ex- 
cised and  wounds 

sutured 


The  diagnosis  now  being  at  hand,  it  was  determined  to  apply  the 
therapeutic  measure  of  choice.  The  wound  had  healed  and  the  sutures 
had  been  removed.  Under  local  cocaine  anaesthesia,  the  scar  of  the 
first  operation  and  the  skin  about  it  for  a  distance  of  4  m.  m.  were  ex- 
cised by  an  elliptical  incision.  This  left  a  wound  too  large  to  close 
by  simple  apposition  sutures.  A  curved  incision  was  carried  from 
either  end  of  the  elliptical  wound,  marking  out  a  flap  on  either 
side,  the  length  of  the  wound,  and  having  a  width  at  their  bases 
equal  to  the  widest  width  of  the  wound  (Fig.  i).  One  of  the  lateral 
flaps  was  made  by  carrying  the  incision  to  the  median  line  of  the  nose, 
the  other  by  carrying  the  incision  to  the  inner  canthus  of  the 
eye.  These  flaps  were  dissected  free,  and  united  in  a  straight  line  over 
the  denuded  area.  The  two  lateral  wounds  were  then  closed  by  in- 
terrupted sutures.  Fine  interrupted  silk  sutures  were  used  (Fig.  2). 
Primary  healing  followed. 

Now  after  twenty-two  years  the  patient  is  here  free  from  any 
suggestion  of  disease,  and  with  a  scarcely  discernible  scar.  It  is  ob- 
served that  he  still,  as  a  matter  of  precaution  and  habit,  wears  his 
glasses  low  down  on  the  nose,  thus  giving  expression  to  the  surgical 
sense  which  prompts  avoidance  of  further  irritation  of  a  once  vulner- 
able area. 

51 


ON  IMPENDING  PERFORATION  OF  GASTRIC  AND 
DUODENAL   ULCERS. 

Carl  Fulda,  M.D. 

IT  must  have  been  noted,  even  by  those  only  superficially  acquainted 
with  the  Hterature  of  perforated  gastric  duodenal  ulcers,  that 
the  mortality  in  this  class  of  cases  is  higher  than  it  should  be  in 
view  of  the  advances  made  in  other  acute  abdominal  conditions.  A 
mortality  of  73  per  cent  ^  or  even  of  40  per  cent  -  does  not  compare 
favorably  with  the  death  rate  of  appendicitis  or  cholecystitis.  And 
yet  these  latter  conditions  frequently  present,  at  operation  at  least, 
far  greater  technical  difficulties  than  do  those  cases  now  under  dis- 
cussion. 

Aside  from  those  determining  factors,  as  age  and  general  condi- 
tion of  the  patient,  which  are  common  to  all  surgical  procedures,  there 
are  two  which  decide  what  shall  be  the  issue,  once  a  perforation  has 
taken  place.     They  are  : 

1.  The  age  of  the  perforation. 

2.  The  operation  performed. 

Considering  the  second  factor  first,  we  find  that  it  has  received 
the  greater  attention.  We  will  grant  at  once  that  a  decided  difference 
in  the  outcome  is  to  be  noted  between  those  cases  in  which  closure 
could  be  performed  and  those  in  which  closure  could  not  be  done.^'^ 
Failure  to  close  the  ulcer  may  be  due  to  inability  to  find  the  perfora- 
tion, to  technical  difiiculties  presented  by  extensive  induration,  or  by 
its  position. 

This  is  admitted  even  by  the  most  skillful  and  "from  the  char- 
acter of  the  condition  and  its  urgency  it  must  happen  that  these  cases 
will  be  operated  upon  by  those  not  of  long  experience  in  emergency 
abdominal  operations."  ^  Petren's  table  shows,  that  while  9  per  cent 
were  saved  where  suture  could  not  be  done,  that  even  where  closure 
was  possible  there  was  still  a  mortality  of  46  per  cent. 

The  most  attention  has  been  given  to  the  question  as  to  whether  or 
not  a  gastro-enterostomy  should  be  added  to  the  closure.  The  sugges- 
tion of  von  Eiselsberg  to  perform  jejunostomy  in  certain  cases  of  this 
type,  has  only  very  rarely  been  followed,  in  this  country  at  least.  As  to 
gastro-jejunostomy,  it  is  advocated:  (i)  When  the  infolding  of 
large  indurated  ulcers  has  resulted  in  obstruction  at  the  pylorus;  (2) 
for  the  reason  that  closure  alone  does  not  cure  the  ulcer  or  a  second 
ulcer  present;  (3)  it  is  maintained  that  closure  does  nothing  to  pre- 
vent subsequent  ulcer  formation ;  and  finally  (4)  because  gastro- 
enterostomy will,  in  addition  to  its  other  advantages,  allow  earlier 
feeding  and  laxative  medication. ° 

As  to  the  question  of  obstruction,  it  will  be  acknowledged  that 
it  is  difficult  to  obstruct  the  pylorus  unless  elaborate  operative  pro- 
cedures are  undertaken. ^-^  \\'"e  have  never  seen  it  occur  even  where 
the  infolding  was  very  extensive.  As  to  late  results,  such  as  obstruction 
and  cicatricial  distortion,  it  has  been  shown  that  this  does  not  occur.''' 
In  regard  to  the  second  point  of  advantage,  enough  cases  have  been 
reported   to   show   that   within   a   short   time   after   perforation   and 

52 


Fig.    1.     Chronic    nicer    of    stomach.      Microscopic    section    from    Case    11. 
All  layers  except  serosa  are  destroyed  and  perforation  is  imminent. 


Fig.  2.     Removed  pylorus  from  Case  II,  with  portion  of  stomach  and  duo- 
denum.    Mucosa  aspect  ulcer  directly  at  pylorus  about  to  perforate. 


closure,  the  ulcers  have  healed  absolutely.  As  objection  to  the  third 
advantage,  that  of  preventing  subsequent  occurrence  of  ulcers,  enough 
evidence  has  been  presented  to  show  that  subsequent  ulcers  do 
occur.2'8'^  Lastly,  these  patients  can  be  fed  as  early  without  gastro- 
enterostomy as  with  it ;  and  as  to  the  administration  of  laxatives,  that 
will  not  generally  be  accepted  as  desirable. 

We  object  to  the  performance  of  gastro-enterostomy  in  these 
cases  of  perforation  because  we  are  not  convinced  that  it  is  a  safe 
procedure  in  the  presence  of  a  peritonitis.  Granted  that  the  infection 
is  of  a  low  grade,  it  must  also  be  allowed  then  that  the  escape  of 
an  acid  gastric  contents  has  lowered  the  resistance  of  the  peritoneum. 
Further,  its  performance  must  add  to  the  length  of  time  of  operation 
and  so  to  the  shock  of  the  perforation  in  a  patient  whose  resistance 
is  low  from  prolonged  gastric  disturbance  and  who  still  has  to  look 
forward  to  a  struggle  with  a  peritonitis.  We  have  never  performed 
a  gastro-enterostomy  in  "five  or  at  the  outside  seven  minutes."  ^ 
Thirty-five  to  forty  minutes,  the  time  stated  by  Eliot  ^  is  more  nearly 
like  the  length  of  time  required  by  most  operators. 

The  danger  of  a  jejunal  ulcer  following  gastro-enterostomy, 
though  slight,  must  be  added  to  the  total  of  evidence  against  it. 
When  we  consider  the  question  of  cancer  formation  on  an  ulcer 
base  ^^  excision  would  be  of  greater  value  than  gastro-enterostomy. 

More  important,  however,  than  all  this,  is  the  fact  that  it  has 
not  been  shown  that  adding  gastro-enterostomy  to  closure  of  the  ulcer 
has  in  the  slightest  degree  lowered  the  mortality  of  perforated  gastric 
or  duodenal  ulcer.  Its  advocates  claim  for  it  some  value  in  the 
patient's  future;  but  the  present  events  in  his  life  are  those  with 
which  we  are  most  concerned.  If  there  were  no  other  valid  reasons 
against  its  being  done,  it  should  be  omitted  for  the  reason  that  it 
adds  nothing  to  the  chances  of  recovery. 

Of  vastly  greater  importance  is  the  question  of  the  time  of 
operation.  On  this  point  there  is,  and  can  be,  no  dispute.  The 
longer  the  interval  between  perforation  and  operation,  the  higher  is 
the  mortality;  the  further  the  peritonitis  has  advanced,  the  less  is 
the  chance  of  recovery. 

Perhaps  because  it  is  generally  accepted,  little  has  been  said  on 
this  point  in  comparison  with  the  amount  of  discussion  on  "gastro- 
enterostomy or  not."  Now,  one  might  suppose  that  from  the  ability 
to  recognize  a  perforation  early  to  the  ability  to  recognize  a  threat- 
ened perforation  would  be  a  natural  progression  of  events.  And  yet, 
with  one  or  two  exceptions,  nothing  has  been  said  on  this  point. 
We  beheve  that  the  important  reduction  in  the  mortality  of  these 
cases  will  come  when  an  imminent  perforation  is  recognized,  and  the 
necessary  surgical  steps  taken ;  and  not  before  that  time.  It  must  be 
remembered  that  early  recognition  and  operation  of  a  perforation, 
though  important,  are  not  alone  sufficient. 

Similar  symptoms,  of  a  perforated  ulcer,  may  accompany 
vastly  different  pathologic  conditions,  as  discovered  at  operation.  In 
one  case  the  perforation  may  be  small  with  little  leakage.  In  others 
there  may  be  a  wide  opening  with  the  escape  of  large  quantities  of 
gastric  juice  and  even  an  entire  meal.  So  that,  even  if  operated  upon 
early  after  prompt  recognition,  there  will  still  be  factors  present 
beyond  our  control  and  variable  in  determining  the  end  results. 
Again,  these  acute  abdominal  conditions  do  not  always  occur  when 
time  and  place  are  convenient  for  patient  and  operator. 

As  a  matter  of  fact  it  is  doubtful  whether  the  exact  time  of 

53 


perforation  is  ever  recognized.  In  the  great  majority  of  cases  it  is 
the  spreading  of  the  peritonitis  that  produces  the  alarming  symptoms. 
The  erosion  has  gone  on  slowly,  approaching  the  serosa  little  by  little. 
The  inflammatory  process  spreads  to  the  peritoneum  which  thickens 
in  its  attempt  to  prevent  the  perforation.  The  threatened  point  is 
further  protected  by  omentum,  sometimes  by  the  under  surface  of  the 
liver,  by  spleen,  or  even  by  the  anterior  abdominal  wall.  As  the 
erosion  goes  on,  one  of  several  events  may  happen.  Either  the  de- 
structive process  goes  on  faster  than  the  protective  process  without, 
or  the  force  within  the  stomach  may  become  too  great,  and  there 
results  more  or  less  profuse  leakage,  and  a  rapidly  spreading  periton- 
itis. It  is  not  denied  that  there  are  cases  in  which  little  or  no  effort 
at  a  protective  process  can  be  seen,  but  in  the  greater  number  of 
cases  the  sequence  of  events  occurs  as  described. 

Epigastric  pain  and  epigastric  tenderness  are  the  most  important 
symptoms  of  impending  perforation  of  gastric  or  duodenal  ulcer. 
Other  symptoms  of  ulcer  may  or  may  not  be  present,  or  have  been 
present.  The  pain  varies  in  severity  a  good  deal  with  the  patient's 
temperament,  but  it  is  decidedly  epigastric,  and,  if  present  in  the 
patient's  past  history,  increased  markedly.  The  tenderness  is  severe 
and  localized,  the  maximum  point  thereof  corresponding  to  the  site 
of  the  ulcer.  Rigidity  of  the  abdominal  wall,  though  present,  is  of  a 
lesser  degree  than  when  the  peritonitis  is  well  under  way.  It  is  true 
that  these,  symptoms  are  present  in  most  cases  of  ulcers,  but  it  is 
their  increase,  their  comparison  with  previous  conditions  that  is 
important. 

It  must  not  be  forgotten  that  chemical,  thermal  and  mechanical 
stimuli  are  felt  only  in  the  upper  and  lower  ends  of  the  alimentary 
tract.  They  are  lost  in  the  upper  esophagus,  and  only  perceived  in 
the  lower  rectum.  Ulcerative  processes  in  the  stomach  and  duo- 
denum do  not  in  themselves  cause  pain  except  when  the  inflamma- 
tory condition  extends  to  the  neighboring  peritoneum.  According 
to  the  direction  in  which  the  lymphatics  carry  the  inflammation,  the 
pain,  by  irritation  of  the  lumbar  and  intercostal  nerves,  may  be  re- 
ferred to  organs  that  also  send  lymphatics  to  these  nerves.  ^^  These 
anatomic  relations  explain  the  frequency  with  which  less  acute  ulcer- 
ative conditions  in  the  stomach  and  duodenum  are  confused  with 
lesions  of  the  gall-bladder,  kidney,  appendix  or  pancreas. ^^ 

Increased  epigastric  pain  and  increased  epigastric  tenderness 
then,  in  cases  with  a  history  of  gastric  or  duodenal  ulcer,  are  to  be 
interpreted  as  meaning  that  the  peritoneum  over  the  lesion  is  taking 
part  in  the  inflammatory  process.  Whether  or  not  the  necrosis  also 
will  extend  to  the  serosa,  that  too,  is  beyond  our  control.  The  im- 
portant fact  is  that  the  perforation  is  imminent  and  prompt  surgi- 
cal interference  is  indicated. 

Brentano^  obser\^ed  that  cases  of  perforated  gastric  and  duo- 
denal ulcer  gave  in  their  histories  prehminary  symptoms  of  perfora- 
tion, such  as  cramps  and  stabbing  pains  and  called  them  "Heralds 
(Vorboten)  of  perforation."  MitchelP^  observed  that  rigidity  and 
tenderness  are  signs  that  the  peritoneum  is  already  involved,  and  are 
danger  signals  of  perforation.  McGuire^*  noted  an  increase  in  pain 
and  tenderness  just  before  perforation.  Noetzel^^  hoped  that  the 
mortality  of  the  perforated  cases  would  be  reduced  by  prophylactic 
means,  that  is,  by  early  operation  of  painful  ulcers.     That  is  what 


54 


Fig.   3.      Removed   pylorus   with   portion   of   stomach    and    duodenum, 
tense   inflammation   of   peritoneum.      Perforation   imminent. 


In- 


FiG.  4.    Removed  pylorus.     Mucosa  side  of  Fig.  3,  showing  part  of  stomach 
and  duodenum,  ulcer  about  to  perforate.     Second  ulcer  is  seen. 


we  wish  to  emphasize  and  indorse,  operation  before,  not  after,  per- 
foration. 

In  the  following  seven  cases  the  diagnosis  of  impending  perfora- 
tion was  made  and  operation  urged.  Case  I  refused  operation  for  the 
reason  that  several  months  before,  he  had  recovered  from  a  similar 
attack  under  medical  treatment.  His  refusal  was  given  in  much  the 
same  manner  that  patients  with  appendicitis,  in  their  second  or  third 
attack,  beg  for  another  trial  of  the  ice-bag.  And  this  we  point  out 
as  an  objection  to  the  medical  treatment  of  painful  ulcers,  that  if  the 
patient  recovers  for  the  time,  as  they  do,  in  later  attacks  much  valu- 
able time  may  be  lost  trying  the  same  treatment  again.  As  a  further 
objection  to  this  plan  of  treatment  we  may  add  that  many  of  these 
cases,  for  economic  reasons  can  ill  afford  to  undergo  these  long  terms 
of  rest.     They  must  be  returned  to  work  as  promptly  as  possible.  ^^ 

Case  I. — German  Hospital.  No.  31546.  O.  B.  27.  Admitted  to  hospital 
April  24,  1915-  History  of  stomach  trouble  for  several  years.  Pain  and 
epigastric  tenderness.  Worse  two  months  ago.  Recovered  under  care  of 
physician,  rest  in  bed,  milk  diet,  etc.  On  readmission,  symptoms  again  worse 
for  several  days.  Operation  advised  by  physician  and  refused.  Twelve  hoiurs 
after  admission  symptoms  alarming.  Operation  April  24,  1915.  Large  indu- 
rated ulcer  high  up  on  lesser  ctuvatiu-e.  Considerable  free  blood  in  epi- 
gastrium. Perforation  only  made  out  by  noting  point  of  escape  of  gastric  con- 
tents.    Infolding  with  one  deep  suture  and  gauze  tampon. 

In  this  case  the  perforation  took  place  while  the  patient  was  in 
bed  in  a  hospital.  Recovery  uneventful,  discharged  thirty-ninth  day 
after  operation. 

Case  II. — German  Hospital.  No.  3031 1.  L.  I/.  49.  History  of  stomach 
trouble  for  years.  Periodic  pain,  vomiting  and  epigastric  tenderness.  Food 
increases  pain.  Recently  all  symptoms  worse.  Retracts  epigastrimn  in  walking. 
Tenderness  in  epigastrimn  over  area  midway  between  umbilicus  and  ensiform. 
Diagnosis,  impending  perforation  of  gastric  ulcer.  Operation  November  12, 
1 9 14.  Large  indiu-ated  ulcer  on  lesser  curvature.  Peritonemn  red  and  thick 
over  lesion.  ]Bxcission  of  ulcer  and  posterior  gastroenterostomy.  Recovery 
uneventful.     Discharged  twenty-first  day  after  operation. 

From  the  illustration  (Fig.  i.)  it  will  be  seen  that  only  the 
thinnest  layer  of  tissue  separates  the  stomach  and  peritoneal  cavities. 
There  is  little  doubt  in  our  mind  as  to  the  probability  of  perforation 
in  this  case. 

Case  III. — German  Hospital.  No.  30903.  W.  D.  22.  Attacks  of  pain 
in  stomach  for  two  years,  lasting  weeks  at  a  time.  Pain  came  on  soon  after  eat- 
ing. Present  attack  began  three  weeks  before  admission.  Artificial  vomit- 
ing brings  relief.  Entire  epigastrimn  tender,  most  marked  to  right  of  point  half 
way  between  umbilicus  and  ensiform.  Operation,  February  5,  1915.  Ulcer, 
indurated,  of  anterior  siuface  of  stomach  near  pylorus.  Peritonetmi  red  and 
thickened.  Posterior  gastroenterostomy.  Recovery  imeventful,  discharged  nine- 
teenth day  after  operation. 

In  this  case  gastroenterostomy  was  deemed  sufl&cient.  The  man 
has  been  well  since. 

Case  IV. — German  Hospital.  No.  33090.  H.  P.  48.  Had  stomach  trouble 
for  five  years.  Sharp  pains  in  epigastrimn  radiating  to  back.  At  first  twice  a 
year,  attacks  are  now  once  a  month  and  more  severe  Ln  character.  Artificial  vomit- 
ing brings  relief.  Four  days  before  admission  pain  is  continuous.  Eat- 
ing does  not  influence  pain!  Diagnosis,  Impending  perforation  of  gastric  ulcer. 
Operation,  November  11,  1915.  Ulcer  high  up  on  lesser  curvature,  adherent 
behind    and    boimd    down.     Much    induration.     Peritonemn  thickened  and  red. 


55 


Posterior     gastroenterostomy.     Discharged     cured     twenty-seventh     day     after 
operation. 

As  in  Case  III,  gastroenterostomy  was  sufficient  to  bring  about 
a  cure.     Patient  has  been  free  from  pain  since. 

Case  V. — German  Hospital.  No.  33257.  C.  G.  34.  One  week  before  ad- 
mission patient  had  pain  in  epigastritim,  stabbing  in  character,  vomited  blood. 
Pain  relieved  by  eating!  Had  tarrystools.  Kpigastrium  rigid  and  very  tender 
over  area  to  right  of  point  half  way  between  umbilicus  and  ensiform.  Diag- 
nosis, impending  perforation  of  ulcer  at  pylorus.  Operation  November  22, 
1915.  Large  induration  of  duodenvmi  pylorus  and  pyloric  part  of  stomach. 
Peritoneum  very  red  and  ulcer  can  plainly  be  felt,  especially  its  thin  base. 
Resection  of  pylorus  and  indurated  area  either  side  thereof.  Posterior  gastro- 
enterostomy.    Discharged  on  thirty-second  day,  cured. 

Aside  from  the  extensive  induration  the  case  presented  the  inter- 
esting feature  of  a  second  ulcer  on  the  gastric  side  of  the  pylorus  (Fig. 
II.).  On  searching  for  this  patient  to  ascertain  his  present  con- 
dition we  learned  that  he  had  contracted  pulmonary  tuberculosis 
and  had  gone  to  some  country  sanitarium  for  treatment. 

Case  VI. — German  Hospital.  No.  33278.  F.  S.  38.  Four  years  history 
of  stomach  trouble.  Boring  pain  in  epigastrium.  Food  aggravated  pain! 
Vomited  no  blood.  Pain  severe  for  last  year.  Starved  on  account  of  fear 
of  food.  Even  milk  caused  excruciating  pain.  Same  pain  day  and  night. 
Entire  epigastrium  very  tender  but  not  rigid.  Diagnosis,  ulcer  at  or  near 
pylorus.  Operation  November  23,  1915.  Entire  pylorus  for  2.5  cm.  (i  inch), 
both  ways  red,  indurated  and  hard.  Ulcer  felt  in  pylorus  with  thin  base. 
Under  surface  of  liver  adherent  over  ulcer  but  easily  freed.  Resection  of 
pylorus  and  posterior  gastroenterostomy.  Discharged  one  hundred  and  sixty- 
ninth  day  after  operation.     (Figs.  Ill  and  IV.) 

It  will  be  noted  that  in  this  case  also,  a  second  ulcer  was  found. 
The  peritoneum  was  intensely  inflamed  and  the  ulcer  base  thin.  On 
the  twenty-eighth  day  after  operation  a  gastric  fistula  appeared 
which  failed  to  close  until  the  hundred  sixty-ninth  day  after  opera- 
tion. 

Case  VII. — German  Hospital.  No.  34408.  P.  S.  25  Denies  any  previous 
history  of  gastric  disturbance.  About  an  hour  before  admission  he  experienced 
sudden  epigastric  pain.  Epigastrium  is  tender  and  rigid.  Maximum  point  of 
tenderness  over  duodenum.  Diagnosis,  impending  perforation  of  duodenal 
ulcer.  Operation  March  30,  1916.  One  and  one-half  hours  after  admission 
pylorus  and  first  part  of  duodenum  adherent  to  anterior  abdominal  wall.  Only 
very  slight  leakage  from  ulcer  at  pylorus  which  may  have  been  started  by 
separating  gut  from  abdominal  wall.  Entire  pyloric  portion  of  stomach, 
pylorus  and  first  part  of  duodenum  indurated.  Adhesions  freed  and  ulcer 
found  in  pylorus  with  base  the  size  of  a  dime.  Whole  indurated  area  infolded 
without  regard  to  occlusion  of  pylorus.  Gauze  strip  to  point  of  infolding. 
Discharged  seventy-nineth   day  after   operation,   cured. 

Dismissal  in  this  case  was  delayed  by  a  suppurative  parotitis  and 
by  repeated  x-ray  examinations.  The  last  report  made  May  22,  1916, 
six  weeks  after  operation,  is :  Plate  of  stomach  shows  good  tone, 
regular  peristalic  wave  and  perfectly  normal  contour  (Report  Num- 
ber 406).  On  the  fifth  day  this  patient  was  taking  all  the  fluids  he 
wanted  and  in  the  twenty-seventh  day  was  eating  regular  mixed  diet. 
He  vomited  only  once,  an  hour  after  operation.  This  case  is  added 
because,  though  there  was  infolding  of  a  greater  amount  of  gut  wall 
than  usual,  there  was  no  ill  effects  noted  and  six  weeks  after  opera- 
tion no  distortion  of  the  stomach  was  observed.  It  must  be  noted 
here,  that  the  infolding  is  done  in  the  long  axis  of  the  stomach  and 
duodenum  which  probably  occludes  less  than  if  the  folds  were  made 
across  the  gut, 

56 


Tabi,e  I. 

Durati®n     Tender- 


No. 
I 

2 

3 

4 

5 
6 
7 
In 


Vomit- 
Pain  ing 
+  +     o 

+ 


Rel. 


of  Food  to  Pain 
worse 
worse 
worse 
none 
relief 
worse 


Age     Loc.  of  Sym.        ness 

2^      Gast.  2  years  4- 

49      Gast.  5  years  -}-+     + 

22      Gast.  5  years  +         +         Induced 

43      Gast.  5  years  +         +         Induced 

34      Duod.  1  week  -f-         ++     + 

38      Duod.  4  years  ++     ++     + 

25      Duod.  o  +         +         +  _  — 

the  table  given,  the  symptoms  are  arranged  in  the  order  of 
their  value  to  us.  It  will  be  noted  that  those  considered  most  import- 
ant are  also  the  most  constant.  It  may  be  added  that  the  same  relative 
value  is  placed  on  these  symptoms  in  dealing  with  less  acute  ulcers 
or  ulcers  already  perforated. 

In  conclusion  we  may  state  that  gastroenterostomy,  of  whatever 
value  in  other  types  of  ulcers,  does  not,  when  added  to  closure  of  a 
perforated  gastric  or  duodenal  ulcer,  improve  the  patient's  chances  of 
recovery.  Though  early  recognition  and  operation  have  given  the 
best  results,  we  submit,  nevertheless,  that  the  hope  for  improvement 
in  the  situation  Hes  in  operation  before  perforation. 


REFERENCES. 

1.  Brentano,  Langenbeck's  Archiv.     Bd.  81,  No.   i. 

2.  Petren,  Surg.   Gyn.   &  Obst.     Vol.  XIV,  p.  555. 

3.  Eliot,  E.     Annals  of  Surgery.     Vol.  LV,  p.  557. 

4.  von  Eiselberg,  Deutsche  Med.   Wchnschft.     1906,  No.  30. 

5.  Patterson,   Surgery   of  the  Stomach,  p.    170. 

6.  Lewisohn,  Surg.  Gyn.   &   Obst.     Vol.  XXII,  p.  379. 

7.  Gibson,  Surg.  Gyn.  &  Obst.     Vol.  XXII,  p.  388. 

8.  Jaboulay,  Archiv.   Prov.  de   Chir.     1906,   No.  9. 

9.  Cuff,  Brit.  Med.  Journal.     1907,  Feb.  2. 

10.  MacCarty,  W.  C,  Surg.  Gyn.  &  Obst.     1910,  p.  447. 

11.  Seyffarth,  Deutsche  Med.  Wchnschft.     1911,  p.  731. 

12.  Lennander,  Centralbl.  f.  Chir.     1901. 

13.  Mitchell,  Annals  of  Surgery.     1911,  Dec. 

14.  McGuire,  E.,  Buffalo  Med.  Journal.^  Vol.  67,  No.  11. 

15.  Noetzel,  von  Bruns  Beitr.  z.  Kl.  Chir.     Bd.  51,  No.  2. 

16.  Schwarz,   Centralbl.  f.   Chir.     1912,  p.  26. 


57 


VI 
THE  JEWISH  HOSPITAL  OF  BROOKLYN. 


CLINIC  AT  THE  JEWISH  HOSPITAL. 
William  Linder,  M.D. 

SPLENECTOMY  FOR  TUBERCULOSIS  OF  SPLEEN. 

Case;  I.  The  patient  is  a  woman  twenty-nine  years  of  age,  who 
for  three  years  has  been  suffering  from  symptoms  referred  to  her 
stomach.  She  has  lost  twenty  pounds  in  weight  and  is  the  subject 
of  progressive  weakness.  She  is  the  mother  of  three  children,  of 
whom  the  youngest  is  one  year  of  age.  She  was  admitted  to  the 
hospital  on  March  27,  1916,  complaining  of  a  lump  in  the  left  side 
of  her  abdomen,  which  was  not  painful  or  tender,  she  is  the  subject 
of  occasional  chilly  feelings. 

Examination  shows  an  emaciated  woman,  with  clear  conjunc- 
tivae, no  petechia,  no  enlargement  of  glands,  with  diffuse  signs  of 
tuberculosis  in  both  lungs.  The  left  half  of  the  abdomen  is  promi- 
nent. There  is  a  marked  diastasis  of  the  recti  muscles.  The  promi- 
nence of  the  abdomen  is  due  to  an  enlargement  of  the  spleen  which 
by  percussion  is  found  to  extend  from  the  ninth  rib  above  to  the 
brim  of  the  pelvis  below.  The  liver  is  enlarged  and  extends  from  the 
fifth  costal  interspace  above  to  i  inch  below  the  umbilicus.  Blood : 
hemoglobin  57  per  cent;  R.B.C.  3,520,000;  W.B.C.  4,200;  Polys.  66 
per  cent ;  slight  poikilocytosis  and  anisocytosis.  Wassermann  negative. 
Urine  normal  except  presence  of  some  colon  bacilli.  Temperature 
upon  admission,  for  the  first  three  days  varied  from  100  to  102,  then 
sank  to  from  99  to  100.     Pulse  from  100  to  120.     Respiration  24. 

Remarks  upon  the  diagnosis :  The  hemolytic  function  of  the 
spleen  has  been  determined  by  experimentation  in  Banti's  disease 
when  we  find  excessive  hemolysis  occurring.  The  removal  of  the 
spleen  in  the  early  stages  of  Banti's  disease  is  attended  by  great 
benefit,  before  secondary  cirrhosis  of  the  liver  with  its  associated 
jaundice,  ascites  and  gastro-intestinal  hemorrhages  occur.  In  this 
connection  the  Gaucher  type  of  splenomegaly  must  be  considered  for 
purpose  of  differentiating.  The  Gaucher  spleen  occasionally  runs  in 
families,  has  no  associated  cirrhosis  of  the  liver,  no  hemorrhages,  no 
jaundice,  no  ascites.  In  this  particular  case  the  blood  picture,  the 
leukopenia,  the  secondary  anemia,  the  associated  enlargement  of  the 
liver  and  the  absence  of  any  glandular  enlargement  suggests  Banti's 
disease.  On  the  other  hand,  the  possibility  of  tuberculosis  of  the 
spleen  must  not  be  overlooked.  Miliary  tuberculosis  of  the  spleen 
usually  produce  only  a  moderate  enlargement.  The  largest  spleen 
recorded  with  tuberculosis  is  the  amyloid  which  accompanies  chronic 
ulcerative  phthisis.  In  this  case  the  diffuse  lung  signs  together  with 
the  X-ray  findings,  the  dyspepsia,  the  temperature  that  subsided  with 
rest  bespeaks  a  possible  tuberculosis.  In  either  event  a  spleen,  such 
as  this,  is  a  menace  to  the  continued  life  and  well-being  of  the  patient, 
was  made  on  the  left  side  extending  from  the  ninth  costochondral 
and  indication  for  removal  is  clear. 

Ether  was  then  administered  by  Dr.  I.  D.  Kruskal.  An  incision 
junction  to  the  outer  third  of  Poupart's  ligament  along  the  outer  side 

61 


of  the  left  rectus  muscle.  The  peritoneum  having  been  opened  and 
the  spleen  exposed,  it  was  found  to  have  a  very  short  pedicle  with 
several  large  bands  of  adhesions  attaching  it  to  the  diaphragm.  A 
better  exposure  was  now  obtained  by  dividing  the  eighth  and  ninth 
costal  cartilages  and  fracturing  the  corresponding  ribs  making  an 
osteo-plastic  flap,  which  when  retracted  brought  the  diaphragm  and 
upper  pole  of  the  spleen  into  clear  view.  The  esophagus  going  into 
the  stomach  was  plainly  seen.  The  operator  remarked  that  an  ulcer 
of  the  cardiac  end  of  the  stomach  could  be  removed  with  ease  by 
this  method  of  exposure.  He  stated  that  he  had  done  a  complete  gas- 
trectomy using  this  incision  with  the  recovery  of  the  patient.  The 
diaphragmatic  adhesions  were  doubly  ligated  and  divided  between  the 
ligatures.  Only  the  upper  pole  of  the  spleen  was  freed.  The  gastro- 
splenic  pedicle  was  then  exposed  and  divided  between  ligatures  until 
the  entire  blood  supply  of  the  spleen  was  controlled.  This  was  ac- 
complished without  disturbing  the  spleen  from  its  bed.  The  spleen 
was  then  lifted  from  its  bed;  inspection  of  the  wound  showed  com- 
plete hemostasis.  The  abdominal  wound  was  then  sutured  in  layers 
and  closed  without  drainage. 

Pathological  report  of  specimen:  gross  weight  1,266  grams;  size 
26  by  14  by  7  cm.  Capsule  very  thick,  marked  increase  in  consistency 
of  parenchyma.  Surface  granular  pinkish  with  areas  here  and  there 
of  bluish  colored  tissue.  Tendency  to  fasicular  arrangement  of  por- 
tion of  the  splenic  pulp.  Many  blood  vessels  with  patent  mouths. 
Microscopic  section  showed  tuberculosis  of  the  spleen. 

CYSTIC  GOITRE;  THYROIDECTOMY. 

Cass  II.  The  patient  was  a  girl  twenty-three  years  of  age  who 
had  been  the  subject  of  a  small  swelling  of  the  neck,  noticeable  for 
ten  years.  Six  years  ago  it  began  to  increase  in  size  and  has  become 
steadily  larger  until  the  present  time.  Now  there  is  a  large  swelling 
occupying  the  left  side  of  the  neck  and  extending  from  the  left  angle 
of  the  jaw  to  one  and  one-half  inches  to  the  right  of  the  median  line, 
and  from  the  clavicle  to  the  lower  edge  of  the  jaw.  The  patient 
suffers  from  cardiac  palpitation  only  after  much  exertion,  there  is 
slight  exopthalmia.  Face  is  flushed;  tonsils  not  enlarged.  Blood 
count:  W.B.C.  13,200;  polymorphonuclears  81  per  cent;  monoculears 
and  transitional  i  per  cent;  lymphocytes  18  per  cent.  Pulse  from 
72  to  88;  temperature  normal.  Dr.  Linder  remarked  that  this  patient 
has  as  yet  manifested  but  slight  symptoms  of  thyroid  toxemia  from 
a  result  of  increased  thyroid  secretions,  although  she  is  very  excitable. 
Her  real  motive  for  applying  for  operation  is  on  account  of  the  dis- 
figurement from  the  growth  and  some  pressure  symptoms.  She  has  a 
simple  cystic  goitre,  but  such  a  goitre  can  produce  secondary  hyper- 
thyroidism, by  pressure  upon  that  part  of  the  thyroid  which  is  still 
active  and  so  stimulating  increased  production  of  secretion.  It  may 
easily  be  converted  into  a  simple  goitre  of  the  Basedow's  type.  In 
the  removal  of  a  goitre  of  this  kind  special  care  is  to  be  observed  to 
avoid  removal  of  the  parathyroid  bodies  producing  myxedema.  The 
patient  was  then  anesthetised  by  ether  oxygen  by  the  endopharyn- 
geal  method  by  Dr.  I.  D.  Kruskal.  A  transverse  collar  incision  extend- 
ing through  the  skin  and  platysma  myoides  was  made  and  the  flaps 
dissected  up  sufficient  to  fully  expose  the  seat  of  operation.  These 
flaps  were  then  protected  with  towels  secured  by  clamps  and  by  gauze 

62 


sponges,  after  which  an  incision  was  made  in  the  median  line  expos- 
ing the  sterna-hyoid  muscles  which  were  retracted  exposing  the  cap- 
sule of  the  thyroid  gland.  After  two  parallel  clamps  had  been  placed 
upon  the  muscles  at  right  angles  to  their  fibres,  at  about  i  inch  below 
the  hyoid  bone,  the  muscles  were  severed  between  the  clamps  and  re- 
tracted. The  large  venous  trunks  on  the  surface  of  the  thyroid  were 
carefully  doubly  ligated  and  cut  between  ligatures,  and  enucleation  of 
the  gland  was  started  at  the  upper  pole,  the  cyst  being  carefully  lifted 
up  as  freed,  the  blood  supply  being  identified  and  controlled.  The 
recurrent  laryngeal  nerve  was  identified.  The  lower  pole  extended 
about  one  and  one-half  inches  below  the  upper  margin  of  the  clavicle. 
It  was  carefully  lifted  up  and  rolled  out  toward  the  median  line, 
and  finally  the  isthmus  was  divided. 

In  the  course  of  this  procedure  the  operator  remarked  that  if  the 
surgeon  carefully  worked  outside  of  the  capsule  and  ligated  all  blood 
vessels  as  they  were  met  with,  the  lymphatic  vessels  would  also  be 
enucleated  and  a  dry  wound  would  result,  and  there  would  be  no 
necessity  of  painting  the  raw  surfaces  with  such  an  antiseptic  solu- 
tion as  Harrington's,  and  drainage  would  be  avoided  for  the  removal 
of  the  excess  of  thyroid  juice  spilt  in  the  field  of  operation  for  future 
absorption  and  the  production  of  subsequent  post  operative  hyperthy- 
roidism. By  the  method  of  operating  which  he  followed  he  left  his 
wound  so  absolutely  dry  that  he  was  able  to  close  it  and  have  no 
trouble  thereafter.  He  was  careful  to  avoid  injury  to  the  nerve  or 
to  the  parathyroid  bodies.  If  he  met  with  any  difficulty  it  was  his 
custom  to  divide  the  isthmus  first  and  study  the  region  of  the  parathy- 
roids and  the  blood  vessels.  At  the  completion  of  the  neucleation, 
the  trachea  exposed  at  the  bottom  of  the  wound  was  found  to  be 
compressed  and  flattened  and  displaced  to  the  right  of  the  median 
line.  After  final  careful  hemostasis  the  muscles  that  had  been  divided 
were  resutured.  A  few  interrupted  subcuticular  catgut  sutures  co- 
apted  the  skin.  The  skin  wound  itself  was  closed  by  special  metal 
clips  which  were  to  be  left  in  place  for  five  days.  The  use  of  these 
clips  was  resorted  to  because  of  the  less  danger  of  skin  infection 
that  attends  such  use.  No  drain  was  put  in  place.  The  operator 
said  that  most  cases  of  this  kind  were  allowed  to  sit  up  at  the  end  of 
twenty-four  hours.  The  subsequent  history  of  this  case  was  an  un- 
eventful recovery. 

ACUTE  HEMORRHAGIC  PANCREATITIS;  EXPLORATORY 
INCISION;  DRAINAGE. 

Case  III.  Woman  thirty  years  of  age;  mother  of  two  children, 
who  gave  history  that  six  years  ago  she  first  experienced  a  severe 
pain  over  the  entire  abdomen,  which  came  on  suddenly.  Was  at- 
tended with  repeated  vomiting  with  chills  and  fever  and  marked 
perspiration  over  the  entire  body.  The  attack  lasted  eight  hours,  at 
the  end  of  which  time  relief  was  experienced.  It  occurred  during 
her  first  pregnancy.  One  and  one-half  years  later,  during  a  second 
pregnancy,  second  month,  she  then  went  through  with  a  similar  at- 
tack, almost  identical  in  its  features.  Eight  months  later  a  third 
attack  occurred  and  for  the  next  five  months  these  attacks  occurred 
every  week  or  two  but  of  less  severity  than  at  first.  They  were  re- 
lieved by  enemata.  Nine  months  ago  these  attacks  again  began, 
although  not  so  severe  as  formerly.     They  were  attended  with  pain 

63 


which  extended  throughout  the  abdomen  and  at  times  radiated  to  the 
right  shoulder.  They  were  attended  with  vomiting,  chills  and  fever 
and  her  abdomen  would  become  moderately  swollen  so  that  it  was 
difficult  for  her  to  assume  a  sitting  posture.  Four  days  previous  to 
admission  to  hospital  she  was  again  seized  with  severe  epigastric  pain, 
which  radiated  to  the  left  lumbar  region,  attended  with  vomiting.  The 
attack  lasted  for  twenty-four  hours,  but  the  vomiting  continued  and 
the  abdomen  began  to  swell.  She  was  constipated.  No  urinary 
disturbance.  In  this  condition  she  was  admitted  to  the  hospital.  Upon 
admission  the  abdomen  was  distended,  the  abdominal  walls  were 
slightly  rigid,  the  epigastric  region  was  doughy  to  the  touch  and  very 
tender.  The  tenderness  was  present  over  the  entire  abdomen ;  no 
abdominal  organs  could  be  palpated.  Also  tender  in  the  left  lumbar 
region,  especially  at  the  right  costovertebral  angle.  Right  trapezius 
tenderness  also  obtained. 

Blood  count:  Total  23,500;  polymorphonuclears  75;  mononu- 
clears I ;  lymphocytes  24.  Temperature  from  loo  to  100.4.  Pulse 
72  to  80.     Respiration  is  normal.     Urine  negative. 

Dr.  Linder  remarked  that  the  previous  history  of  this  patient 
indicated  typical  attacks  of  gall  stone  colic.  The  last  attack  started 
four  days  ago  which  differed  from  her  previous  attacks  for  these 
reasons :  The  pain  was  referred  to  the  mid  abdomen  which  radiated 
to  the  left  of  the  median  line  around  to  the  lumbar  region.  Upon 
inspection  both  the  abdomen  and  face  showed  a  slight  cyanosis.  Pal- 
pation revealed  a  distended,  soft,  doughy  abdomen  with  a  sense  of 
fullness  in  the  mid  epigastrium  and  tenderness  extending  to  the  left 
of  the  median  line  with  special  tenderness  at  the  costo-vertebral  angle. 
No  special  tenderness  over  the  gall  bladder  and  no  palpable  gall  blad- 
der could  be  found.  The  diagnosis  of  chronic  cholelithiasis  and  acute 
hemorrhagic  pancreatitis  was  probable,  and  an  exploratory  abdominal 
incision  is  called  for. 

Ether  was  then  administered  by  Dr.  Kruskal,  and  the  abdomen 
was  opened  through  a  right  rectus  incision ;  coils  of  distended  bluish 
small  intestines  appeared  in  the  wound.  The  gall  bladder  Avhen  ex- 
posed was  found  to  contain  numerous  gall  stones.  It  was  thin  walled 
and  bluish,  no  obstruction  of  the  cystic  duct.  Palpation  with  the 
finger  in  the  foramen  of  Winslow  showed  no  stones  either  in  the 
Ampulla  of  Vater  or  in  the  common  duct.  Through  the  gastro- 
hepatic  omentum  an  opening  was  bluntly  made  by  the  finger  to  ex- 
pose and  explore  the  pancreas.  Some  serosanguinous  fluid  escaped 
from  the  opening.  After  carefully  sponging  the  cavity  exposed,  the 
pancreas  was  seen  to  be  chocolate  colored,  containing  numerous  patches 
of  fat  necrosis.  The  pancreas  was  punctured  in  four  or  five  places 
with  a  blunt  instrument,  and  a  split  rubber  tube  containing  gauze  was 
placed  down  in  the  retro-peritoneal  space.  The  gall  bladder  was 
opened  and  its  contained  stones  were  removed. 

Dr.  Linder  remarked  that  primary  hemorrhage  into  the  pan- 
creas does  occur  producing  the  typical  lesion  of  fat  necrosis.  If  this 
hemorrhage  is  not  too  great,  these  attacks  may  not  be  recognized,  and 
the  patient  may  get  well  from  a  slight  hemorrhage,  but  such  hemor- 
rhages have  a  tendency  to  recur  and  unless  recognized  and  operated 
upon  usually  ultimately  terminate  fatally.  The  old  conception  that 
diagnosis  of  acute  pancreatitis  cannot  be  made  except  at  an  autopsy 
table,  or  if  made  the  cases  end  fatally,  does  not  hold  today.  In  his 
own  service  at  the  Jewish  Hospital  they  have  records  of  at  least 

64 


twenty-four  cases  of  acute  hemorrhagic  pancreatitis  during  the  past 
six  years  and  fully  75  per  cent  had  been  diagnosed  or  suspected  be- 
fore operation.  It  is  important  that  in  all  operations  upon  the  upper 
abdomen,  where  the  pathology  is  not  clear,  that  the  pancreas  should 
be  exposed  and  inspected.  If  this  routine  was  followed  a  great 
many  more  cases  would  be  diagnosed,  at  least  on  the  operating  table. 
The  history  of  the  case  just  operated  upon  is  typical  of  acute  hemor- 
rhagic pancreatitis  in  its  early  and  mild  stage.  When  the  pancreas 
was  exposed,  however,  extensive  hemorrhages  were  found.  One  of 
the  most  frequent  conditions  that  acute  hemorrhagic  pancreatitis  is 
mistaken  for  is  acute  intestinal  obstruction.  Pain,  vomiting,  abdominal 
distention  and  obstipation  occur  in  both  conditions,  but  the  pain  in 
acute  hemorrhagic  pancreatitis  is  more  severe.  It  is  so  great  often 
that  a  half  grain  of  morphine  does  not  relieve  it.  In  intestinal  ob- 
struction vomiting  is  more  profuse.  The  differentiating  from  gastric 
or  duodenal  perforation  is  to  be  made  by  the  absence  of  the  scaphoid 
abdomen  and  the  boardlike  rigidity  and  also  the  absence  of  any 
previous  history  of  gastric  or  duodenal  ulcer. 

The  after  history  of  the  patient  operated  upon  was  an  uneventful 
recovery. 


65 


VII 
THE  BROOKLYN  HOSPITAL. 


THE  ORIGIN  AND  COURSE  OF  CHRONIC  PERITYPHIL- 

ITIS 

John  Edward  Jennings,  M.  D. 
Surgeon  Brooklyn  Hospital;  Surgeon-in-Chief  Greenpoint  Hospital. 

THERE  is  a  group  of  cases  in  which  the  symptoms,  which  had  been 
attributed  to  the  irritation  caused  by  a  chronically  inflamed  ap- 
pendix, persist,  after  the  removal  of  that  organ  to  the  annoy- 
ance of  the  surgeon  and  patient  alike.  Forced  upon  the  attention  by 
the  fact  that  the  symptoms  are  unrelieved  by  operation,  it  is  evident 
that  conditions  exist  in  the  right  iliac  fossa  which  resemble  chronic 
appendicitis  in  symptomatology  but  are  due  to  other  causes.  The 
situation  is  complicated  by  the  fact  that  almost  all  removed  appendices 
are  declared  somewhat  abnormal  by  the  sympathetic  pathologist  and 
that  complete  relief  of  symptoms  occasionally  follows  the  excision  of 
organs  very  slightly  changed  in  gross  appearance  from  the  normal. 
This  has  led  to  increased  interest  in  this  region  with  the  recognition 
and  study  of  various  pathological  conditions  associated  with  pain, 
constipation  and  digestive  disorders. 

The  French  recognized,  nearly  twenty  years  ago,  a  clinical  picture 
which  has  been  described  under  the  term  "Typhlo-colite"  or  "Typh- 
lite  ptosique."  Dieulafoy  pointed  out  that  there  were  attacks  of 
pain  in  the  ileo-cecal  region  which  had,  he  thought,  nothing  to  do 
with  the  appendix  but  which  signified  the  localization  of  a  muco 
membranous  colitis  in  the  cecum.  The  attack  resolves  itself  into  a 
severe  seizure  of  pain  about  the  cecum  which  lasts  only  a  few  hours 
and  disappears  quite  suddenly.  If  the  patient  is  examined  during  the 
attack  it  will  be  found  that  tenderness  exists  on  pressure  in  the  illiac 
fossa  but  that  there  is  no  rigidity.  In  many  cases  an  elastic  body  can 
be  felt  which  may  vanish  under  pressure  and  appears  to  be  the 
distended  cecum.  Vomiting  may  be  present  with  a  slight  rise  of 
temperature  and  a  spontaneous  diarrhea  often  ends  the  attack:  more 
or  less  tenderness  sometimes  presists. 

More  recently  the  same  condition  has  been  described  in  Germany 
under  the  name  of  "Cecum  mobile,"  or  "Typhlatonie,"  etc. 

In  this  country,  Jackson,  Flint  and  others  have  described  the 
fine  vascularized  membranes  found  upon  the  ascending  colon  or 
cecum.  "The  membrane,"  Jackson  says,  "does  not  resemble  the 
ordinary  conception  of  an  adhesion.  It  is  never  adherent  to  the  ab- 
dominal wall  nor  to  any  contiguous  portion  of  the  small  intestine. 
Instead  it  resembles  more  closely  than  anything  a  thin  pterygium. 
In  recent  cases  the  membrane  is  quite  free  and  produces  but  limited 
restriction  of  the  underlying  colon.  In  more  advanced  and  character- 
istic cases  it  seems  to  bind  the  colon  close  to  the  posterior  abdominal 
wall  and  produces  such  marked  angulations  and  convolutions  of  the 
colon  as  to  practically  produce  a  stricture  of  its  lumen." 

The  Theories  as  to  Etiology  are  three: 

69 


I — That  it  is  congenital, 

2 — That  it  is  mechanical — a  physiological  response  to  trac- 
tion. 
3 — That  it  is  inflammatory,  either  from  a  spreading  peri- 
tonitis from  pomts  of  original  infection  without  or 
from  infections  within  the  contiguous  gut. 
The  studies  of  Flint  and  of   Eisendrath  and   Schnoor  may  be 
accepted  as   determining  the   congenital   origin   of   these   structures. 
"They  originate,"  to  quote   from  Flint,   "after  the   rotation  of  the 
gut  from  the  secondary  fusions  of  the  peritoneum  when  the  cecum 
becomes  attached  to  the  posterior  abdominal  wall  just  over  the  kid- 
ney  and   under   the    liver.      In    some   instances    these    attachments, 
usually  confined   to   the   posterior   aspect  of   the   cecum   and   colon, 
are  excessive  and  extend  out  over  the  ventral  surface  of  the  first 
part  of  the  large  intestine  resulting,  with  the  subsequent  descent  of 
the  cecum,  in  their  being  drawn  in  the  form  of  a  thin  veil  or  mem- 
brane.    In  this  process  the  blood  vessels  take  part,  a  fact  which  ex- 
plains the  long  unbranching  course  from  their  origin  on  the  parietal 
peritoneum  downward  and  forward  onto  the  cecum  or  colon  where 
they  communicate  with  those  of  the  intestinal  wall." 

Eastman  called  attention  to  "the  striking  similarity  of  the  foetal 
peritoneal  fold  described  by  Jonesco  and  Juvara  and  designated  by 
them  the  parieto-colic  fold  to  the  adult  peritoneal  anomaly  described 
by  Jackson  as  membranous  pericolitis  and  generally  known  as  "Jack- 
son's veil,"  and  also  to  the  probable  casual  relationship  between  the 
bloodless  fold  described  by  Treves  and  a  pocket-like  anomalous  peri- 
toneal reflection  which  is  not  rare  in  the  adult  and  which  passes  from 
the  mural  peritoneum  upon  the  right  side  quite  low  down,  extending 
upward  and  inward  over  the  caput  coli  and  vermiform  appendix,  to 
be  attached  to  the  last  two  or  three  inches  of  the  ileum  and  to  the 
peritoneum  of  the  caput  coli.  It  forms  the  boundary  of  a  pre-colic 
fossa  in  which  the  cecal  head  and  the  appendix  may  rest,  as  in  a 
pocket.  It  is  likely  that  the  caput  coli  with  the  appendix  are  not 
rarely,  during  operations  for  appendicitis,  shelled  out  of  this  peritoneal 
fold,  that  is  the  bloodless  fold  of  Treves,  which  forms  the  pocket, 
being  looked  upon  by  the  operator  as  an  affair  of  adhesion  forma- 
tion." He  also  at  the  same  time  called  attention  to  the  fact  that, 
"Douglas  Reid  has  described  under  the  name  Genito-Mesenteric 
Fold,  a  rather  common  foetal  fold  of  peritoneum  which  passes  from 
the  terminal  portions  of  the  ileum  into  the  pelvis"  and  connected  it 
with  the  formation  of  the  so-called  Lane's  kink,  and  frequent  as- 
sociation of  appendicitis  and  oophoritis. 

We  distinguish  the  following  anatomical  forms  of  these  veils 
or  membranes : 

I — The  parieto-colic,  in  which  the  veil  stretches  from  the 
parietal  peritoneum  at  the  hepatic  flexure  over  the 
lateral  and  ventral  surfaces  of  the  ascending  colon 
and  cecum. 
2 — The  parieto-cecal,  which  extends  from  the  parietal  peri- 
toneum lower  down,  passes  over  the  head  of  the  ce- 
cum and  may  merge  with  the  first  type  above. 
3 — ^The  parieto-ileo  appendicular,  or  fold  of  Treves. 
4 — The  genito-mesenteric  or  ileo-pelvic. 

5 — The  omento-colic,  of  Flint,  which  passes  over  the  ven- 
tral aspect  of  the  colon  and  is  continuous  with  the 
omentum. 

70 


Eisendrath  and  Schnoor  from  observations  during  operations 
and  from  examination  of  ten  foetuses,  confirmed  the  position  of  East- 
man and  drew  attention  to  the  similar  parieto-colic  and  genito-mesen- 
teric  folds  on  the  left  side.  They  reported  a  case  which  affords 
proof  of  the  role  which  the  Jackson's  veil  may  play  in  the  produc- 
tion of  acute  and  chronic  obstruction  of  the  ascending  colon  and 
cecum.  "We  are  not  prepared  to  state  at  the  present  time,"  they 
write,  "what  causes  this  change  in  the  peri-colic  membrane  from 
an  innocent  persistent  foetal  structure  to  the  production  of  a  distinct 
pathological  entity."  We  may  then  consider  the  normal  anatomy 
of  the  peri-colic  folds  as  sufficiently  established  for  us  to  advance 
their  gross  pathology  and  the  nature  of  the  process  which  brings 
it  about.  In  a  number  of  cases  of  acute  appendicitis  operated  on 
during  the  attack  the  condition  of  the  peri-colic  membranes,  which 
were  present,  have  been  observed.  In  many  of  these  the  veil  was  found 
edematous,  somewhat  thickened,  pearly  grey  in  color;  and  in  several, 
small  portions  were  removed  for  section  and  culture.  The  sections 
show  round  cell  infiltration;  and  the  cultures,  a  pure  growth  of  colon 
bacillus.  In  all  of  these  cases  the  peritoneum  itself  was  not  in- 
volved, and  the  process  seemed  to  be  a  distinguishing  symptom. 
Localized  areas  of  injection  and  thickening  were  made  out  and  from 
one  of  these  the  colon  bacillus  was  isolated.  It  seems  fair  to  assume 
that  the  contraction  and  band  formation,  which  is  found  in  later 
cases,  are  direct  sequelae  of  this  infectious  process.  I  have 
also  observed  four  cases  in  which  the  process  of  veil  con- 
traction on  the  right  side  has  been  recognized  at  operation  and 
at  a  later  date  symptoms  have  arisen  which  have  been  due  to  a 
similar  process  initiated  on  the  left.  These  cases  have  also  had 
more  or  less  colitis.  I  think  we  may  safely  say  that  just  as  we  know 
how  acute  infection  spreads  from  the  appendix  behind  the  peritoneum, 
so  it  may  be  recognized  that  a  more  chronic  inflammation  in  certain 
cases  follows  the  same  paths.  This  inflammation  may  be  of  short 
duration  and  followed  by  resolution,  as  may  be  seen  if  one  notes 
conditions  at  operation  in  many  catarrhal  cases.  It  may  be  slowly 
progressive  with  remissions  and  exaccerbations  and  it  may  leave  in 
its  wake  contractures  and  adhesions.  There  are  cases  in  which  a 
definitely  progressive  history  is  obtainable,  beginning  as  a  larvate 
appendicitis,  advancing  through  the  stage  of  ileocecal  disablement  to 
the  beginning  of  a  chronic  colitis  with  involvement  of  the  splenic 
flexure  and  sigmoid  in  the  peri-colic  process.  It  seems  fair,  to 
some  authors,  to  consider  these  cases  examples  of  a  descending  colitis, 
and  to  charge  the  peri-colitic  bands  to  infection  through  the  epiploic 
appendages. 

The  disease  may  then  be  defined  as  follows :  Chronic  perityphlitis 
is  a  process  characterized  by  the  presence  of  areas  of  subperitoneal 
congestion,  inflammation  and  cicatrical  retraction  accompanied  by 
disturbances  of  ileo-colonic  function,  by  catarrhal  and  croupous  in- 
flammation of  the  cecum  and  ascending  colon  and  sometimes  initiat- 
ing a  descending  colitis  and  peri-colitis.  The  fact  that  these  areas 
may  be  seen  inflamed  during  an  acute  attack  of  appendicitis,  that 
one  or  more  of  them  are  often  seen  inflamed,  an  exacerbation  of 
chronic  right  iliac  pain  and  that  most  of  them  recovered  completely 
after  the  appendix  had  been  removed  render  it  probable  that  the 
infection  takes  its  rise  most  often  in  the  appendix.     The  fact  that 


71 


some  of  them  continue  to  give  symptoms  after  the  appendix  has 
been  removed  calls  for  explanation.  Is  the  continuation  of  trouble 
due  to  irritation  from  the  scars  of  contractures  unrelieved  by  opera- 
tion or  is  it  due  to  recurrent  attacks  of  inflammation  set  up  by  in- 
fection in  the  terminal  ileum,  in  the  cecum,  or  in  the  ileo-colic  glands  ? 
I  am  persuaded  that  each  of  these  situations  may  furnish  a  nidus 
from  which  recurrent  spreading  infections  may  arise. 

The  terminal  ileum  is  rich  in  lymphatic  tissue,  it  is  the  site  of 
ulceration  in  typhoid,  in  tuberculosis  and  perhaps  more  often  than  we 
now  admit,  of  infections  not  yet  recognized  as  specific.  In  a  recent 
case  a  well  defined  ulcer  with  edges  as  indurated  as  the  usual  duodenal 
type,  involved  two-thirds  of  the  circumference  of  the  ileum  from 
the  ileo-cecal  valve  backward  about  two  inches.  It  would  seem,  how- 
ever, that  this  type  of  disease  must  be  rare. 

The  ileo-colic  glands  are  not  infrequently  found  quite  distinctly 
involved  in  a  definite  group  of  cases  of  appendicitis,  most  often  ob- 
served in  children  and  adolescents.  These  cases  occur  as  an  immed- 
iate sequel  of  a  tonsillitis.  On  the  second,  third  or  even  the  fourth 
day  of  throat  infection  abdominal  pains  and  vomiting  begin.  The 
temperature  is  usually  rather  high,  103  to  104°  F,  and  as  the 
general  abdominal  pain  and  tenderness  becomes  localized  it  is  often 
possible  to  recognize  that  it  is  somewhat  higher  and  nearer  the  navel 
than  the  usual  site  of  appendicular  distress.  Some  of  these  cases 
go  on  to  suppuration  or  gangrene,  but  most  of  them  subside  with  rest. 
If  such'  a  case  be  opened  in  the  catarrhal  stage  one  finds  that  the 
glands  in  the  ileocolic  angle  are  much  enlarged  and  that  this  is  much 
more  noticeable  than  the  involvement  of  the  appendix  which  may 
even  appear  nearly  normal.  There  will  be  found,  however,  the  same 
retroperitoneal  injection  and  edema  that  has  been  mentioned  before. 

The  relation  of  stercoral  typhilitis  to  peri-typhilitis  is  doubtful 
It  has  been  noted  that  the  disease  has  a  tendency  to  progress  and  to 
involve  the  left  side  and  this  appears  in  two  different  ways :  In  the 
first,  a  catarrhal  colitis  is  followed  by  the  appearance  of  pain  and 
sensation  of  gas  lodged  on  the  left  side.  These  "gas  balloons,"  as 
some  of  the  patients  call  them,  are  high  on  the  left  side — this  may 
be  called  the  diverticular  type.  In  the  second,  after  signs  of  right 
ovarian  irritation,  constipation  increases  and  the  sensation  of  "gas 
balloons"  appears  low  on  the  left  side. 

The  first  variety  seems  to  be  due  to  an  extension  within  the  colon 
and  its  dissemination  in  the  region  in  which  diverticulae  are  most  often 
found. 

The  second  is  due  to  a  spread  of  the  subperitoneal  process 
around  the  pelvic  brim,  apparently  advancing  with  the  congestion 
of  each  menstrual  period.  These  patchy  areas  of  injection  and 
edema  may  be  seen  in  cases  not  too  far  advanced,  in  which  proper 
search  is  made. 

There  is  a  variety  of  peri-colic's  which  apparently  originates  in 
the  gall  bladder  and  descends  involving  the  parieto-colic  and  omento- 
colis  folds  and  causing,  in  its  later  stages,  a  rather  confused  picture  of 
upper  and  lower  disease  on  the  right  side. 

The  condition  is  to  be  suspected  in  cases  of  long  standing,  inter- 
mittent right  iliac  pain  and  tenderness,  in  dyspepsia  with  tenderness 
in  the  right  iliac  fossa,  although  no  complaint  of  pain  is  often  made. 
These  are  typically  ileal  cases  rather  than  cecal. 

It  should  also  be  suspected  in  dysmemorrhea  of  young,  unmarried 

72 


women,  especially  if  right  sided  ache  persists  between  periods  and 
the  digestion  is  affected.  The  signs  are:  tenderness  and  pain  in  the 
same  spot  or  spots  at  different  times,  often  increased  by  exercise; 
delay  of  bismuth  meal ;  tenderness  and  pain  on  inflation  of  the  colon. 
These  cases  should  be  carefully  distinguished  from  those  in  which 
atony  and  dilatation  of  the  cecum  exist  without  inflammation  or  ob- 
structive retraction  in  the  neighborhood.  Such  cases  constitute  quite 
another  group,  probably  to  be  dealt  with  in  the  same  chapter  with 
local  vagotonia,  certainly  not  here. 

Treatment:  A  liberal  incision  through  the  middle  or  around  the 
outer  edge  of  the  right  rectus  should  be  made  so  as  to  reveal  the 
terminal  ileum,  the  cecum  and  the  ascending  colon  and  give  access, 
if  necessary,  to  the  right  side  of  the  pelvis.  The  appendix,  the 
cecum  and  its  neighborhood,  the  situations  in  which  inflamed  veils 
are  to  be  found,  are  all  investigated,  as  is  the  gall  bladder  region. 
The  appendix  is  removed  and  if  no  perityphlitis  is  found  nothing  else 
is  done.  If  there  is  present  also  a  dilated  and  prolapsed  cecum  with 
evidence  of  inflamed  parieto-colic  veils,  the  veils  are  severed  with 
a  knife,  not  torn,  bleeding  points  caught  and  tied,  and  the  dragging 
cecum  suspended  in  a  slit  in  the  parietal  peritoneum.  If  the  process 
involves  the  pelvis  and  the  terminal  ileum,  this  is  taken  care  of  by 
slitting  the  ligament,  binding  down  the  ileum,  and  covering  the  raw 
area  either  by  folds  of  the  broad  ligament  or  by  unrolling  the  mesen- 
tery or  by  rotating  the  cecum  inward  as  circumstances  may  suggest. 
If  the  ileo-cecal  glands  are  much  enlarged  they  may  be  removed  by 
careful  dissection.  If  the  disease  is  of  long  standing  and  the  cecum 
and  ascending  colon  are  bound  down  by  retracted  bands,  especially 
if  colitis  has  begun  to  be  evident,  it  is  better  and  safer  to  remove 
the  cecum  and  ascending  colon  and  anastomose  the  ileum  into  the 
beginning  of  the  transverse  colon.  In  the  cases  of  the  longest  stand- 
ing in  which  the  muco-membranous  colitis  has  set  up  toxic  symp- 
toms and  in  which  the  patients  are  much  reduced,  the  surgical  treat- 
ment should  be  done  in  several  stages.  The  appendix  should  be  re- 
moved if  this  has  not  already  been  done,  a  cecostomy  or  appendicos- 
tomy  made  for  irrigation  and  an  ileo-sigmoidostomy  performed.  At 
a  later  date,  if  necessary,  the  colon  may  be  removed  or  as  much 
of  it  as  seems  desirable.  Such  measures  will  only  be  necessary  in 
cases  in  which  the  colitis  has  progressed  so  far  as  to  make  simpler 
measures  hopeless.  It  is  desirable  that  the  cases  should  be  recognized 
early  and  taken  care  of  at  that  time. 


73 


SURGICAL  CONSIDERATIONS   OF  ACUTE  DIFFUSE 
PHLEGMONOUS  GASTRITIS. 

Richard  Ward  Westbrook,  M.  D. 

Surgeon  to  the  Brooklyn  Hospital. 

MONG  the  less  well-known  surgical  diseases  of  the  stomach 
is  the  so-called  acute  diffuse  phlegmonous  gastritis.  The  dis- 
ease will  never  attract  wide  discussion  as  it  is  fortunately  rare. 
It  is  at  the  same  time  so  fatal  that  it  is  unlikely  that  the  most  skillful 
diagnosis  and  the  best  surgical  treatment  will  ever  save  more  than 
an  extremely  small  percentage  of  cases.  It  is,  however,  neces- 
sary that  the  unsatisfactory  condition  of  our  surgical  knowledge 
of  this  disease  should  be  cleared  up.  Suggestions  made  by  certain 
well-known  abdominal  surgeons  as  to  treatment  are,  I  am  sure, 
quite  inadequate.  Some  years  ago  it  was  my  good  fortune  to  ob- 
serve and  operate  upon  a  case  of  true  acute  diffuse  phlegmon  of 
the  stomach  which  forms  the  basis  of  this  article.  This  case, 
like  all  the  other  authentic  cases,  was  fatal  in  the  outcome,  but 
showed  clearly  the  conditions  which  must  be  met,  if  surgery  may 
ultimately  be  successful  in  its  treatment. 

Historical.  It  is  stated  that  the  first  mention  of  this  rare  disease 
was  made  by  Varandaeus  in  1620.  In  the  same  century  further  data 
were  furnished  by  Borel  (1656)  and  Sand  (1695).  Occasional  ref- 
erences to  the  condition  are  found  until  1874  when  an  important  paper 
by  Lowenstein  appeared,  and  another  in  1896  by  Leith,  of  Edinburgh. 
At  the  present  time  some  100  cases  have  been  reported. 

There  are  two  distinctly  marked  varieties  of  phlegmon  of  the 
stomach:  the  circumscribed  form,  or  abscess  of  the  stomach  wall,  of 
which  but  few  cases  are  reported;  and  the  diffuse  form — with  which 
we  have  to  do  chiefly  in  this  paper — known  as  acute  diffuse  phlegmon- 
ous gastritis.  A  case  of  the  circumscribed  variety  has  been  operated 
upon  by  Dr.  J.  Wesley  Bovee,  of  Washington,  who  recognized  an 
abscess  of  the  stomach  wall  after  abdominal  section,  opened  and 
drained  the  same,  and  was  rewarded  with  a  recovery.  A  second 
case  of  this  variety  was  treated  by  partial  gastrectomy,  six  months 
after  the  onset  of  acute  symptoms,  by  F.  Koenig,  with  recovery. 
No  authentic  case  of  the  diffuse  form  has  ever  been  known  to  recover, 
and  in  only  two  authentic  cases — my  own  and  a  later  one  of  J.  E. 
Adams  of  London — has  the  diagnosis  been  made  previous  to  autopsy. 

Pathology.  The  diffuse  form  of  phlegmon  of  the  stomach  has 
been  likened  to  a  virulent  erysipelas.  The  parallel  is  striking,  the 
streptococcus  being  responsible  for  both  conditions,  the  deeper  form 
of  erysipelas  spreading  in  the  subcutaneous  tissues  and  often  form- 
ing pus,  very  much  as  the  phlegmon  of  the  stomach  wall  extends  into 
the  submucous  area,  also  with  the  formation  of  pus. 

The  stomach  wall  is  much  thickened,  sometimes  eight  or  nine 
times  greater  than  the  normal.  The  thickening  is  greater  in  the 
pyloric  portion,  where  the  disease  commences  and  from  which  it 
may  spread  to  the  whole  of  the  stomach.  The  thickening  lies  chiefly 
in  the  submucous  coat.  This  is  white,  or  grayish-white,  in  color, 
and  pus  may  often  be  squeezed  from  small  openings  in  it.     Micro- 

74 


scopically  it  is  seen  to  be  crowded  with  immense  numbers  of  round 
cells,  in  the  later  recorded  cases,  the  streptococcus  has  been  the 
organism  found  most  abundantly.  The  lining  mucous  coat  is  usually 
intact,  but  in  the  later  stages  may  be  ulcerated  through  by  the 
underlying  suppurative  process.  The  muscular  coat  is  intact  at  the 
start,  but  may  also  later  be  destroyed  in  part,  allowing  pus  to  pene- 
trate it  to  the  peritoneal  coat.  The  peritoneal  coat  very  rarely  is  per- 
forated, but  usually  becomes  involved  in  local  peritonitis. 

The  so-caUed  circumscribed  form  of  phlegmonous  gastritis  is 
due  to  bacterial  invasion  of  the  submucous  coat,  but  of  a  milder  nature. 
The  staphylococcus  is  probably  the  infective  organism.  The  mucous 
and  muscular  coats  are  thinned  and  pushed  away  from  the  abscess  in 
the  submucous  layer.  The  localized  abscess  which  forms  may 
vary  from  the  size  of  a  bean  to  three  times  the  size  of  the  closed 
fist.  It  may  rupture  into  the  lumen  of  the  stomach,  or  into  the  per- 
itoneal cavity.  The  rest  of  the  stomach  may  show  little  or  no  change. 
This  form  has  been  supposed  to  go  on  to  spontaneous  cure  in  a  num- 
ber of  instances,  where  pus  has  been  vomited.  Vomiting  of  pus,  how- 
ever, may  be  secondary  to  any  perigastric  abscess  wherever  arising. 
Early  operation  in  abscess  should  be  productive  of  good  results. 

Etiology.  The  etiology  of  diffuse  phlegmonous  gastritis  is  as 
yet  obscure.  It  is  far  more  common  in  men  than  in  women,  at 
least  in  a  proportion  of  5  to  i.  It  is  chiefly  a  disease  of  early  adult 
or  middle  life.  A  large  proportion  of  the  cases  reported  have  been 
addicted  to  alcholic  excess.  All  but  a  few  of  the  cases  are  primary 
or  "idiopathic"  in  their  origin,  and  but  a  few  are  secondary  to 
pus-infections  elsewhere.  A  few  cases  followed  operation  on  the 
stomach,  such  as  gastroenterostomy,  and  a  few  were  secondary  to 
the  presence  of  gastric  cancer.  Gastric  ulcer  has  been  antecedent 
in  only  a  few  cases. 

It  is  probable  that  the  infectious  organisms  gain  entrance  to 
the  stomach  wall  through  the  blood  current  rather  than  through  any 
abrasion  of  the  mucous  lining,  as  evidence  of  the  latter  is  rarely 
found.  If  the  latter  were  the  case,  we  should  expect  it  to  more  often 
accompany  gastric  ulcer  and  cancer. 

Symptomatology.  The  symptomatology  in  the  early  stages  of  the 
disease,  before  the  onset  of  peritonitis,  I  believe  may  be  considered 
fairly  characteristic,  although  authorities  state  that  we  can  hardly 
do  more  than  guess  at  the  diagnosis.  I  am  strongly  of  the  opinion 
that  I  should  be  able  to  make  the  diagnosis  in  a  second  case  so 
characteristic  as  my  own. 

It  is  a  violent  disease  from  the  start,  and  its  abrupt  onset  may 
suggest  corrosive  poisoning.  The  earliest  and  perhaps  most  per- 
sistent symptom  is  vomiting.  This  is  repeated  at  short  intervals  and 
is  so  continuous  as  to  be  a  very  distressing  feature.  It  is  said  to 
cease  in  some  cases  a  day  or  two  after  the  onset,  and  later  to  recur 
as  peritonitis  advances.  The  vomited  material  is  watery,  becoming 
bile-stained,  and  later  darkish  as  it  contains  more  material  from  the 
upper  bowel. 

Pain  soon  follows  the  sudden  onset  of  the  vomiting,  and  becomes 
the  most  prominent  symptom.  It  is  localized  in  the  epigastrium, 
and  is  severe  and  continuous.  In  some  cases  it  is  said  to  be  delayed, 
or  absent. 

Pressure  over  the  epigastrium  elicits  marked  tenderness.  Rigid- 
ity is  not  of  high  degree  before  peritonitis  has  advanced,  but  there 

75 


is  present  a  very  distinct  sense  of  increased  resistance  in  the  epi- 
gastrium, over  an  area  which  the  hand  may  cover. 

The  pulse  at  first  is  full,  but  acquires  fairly  early  a  weak  and 
rapid  character.  The  temperature  may  range  from  ioo°  to  105°. 
Chills  often  occur.  Constipation,  or  constipation  preceded  by  diar- 
rhoea, is  apt  to  be  the  rule.  Diarrhoea  sometimes  exists.  The  thirst 
is  extreme  as  a  result  of  the  inflammation  and  the  constant  vomiting. 
Hiccough  is  commonly  present.  The  patient's  mental  anxiety  and 
restlessness  are  very  pronounced,  and  he  has  the  appearance  of  being 
very  gravely  ill. 

Leith  states  that  the  average  duration  of  the  cases  analyzed  by 
him  was  six  and  a  half  days  before  death  occurred.  It  may  occur 
much  earlier.  Death  is  produced  by  septicemia  with  general  peri- 
tonitis. 


Acute 
Pancreatitis. 

Perforated      Gastric 

or 

Duodenal  Ulcer. 

PhlegmonouB 
Gastritis. 

Previous 
history 

Healthy,    or    occas- 
ional   attacks   of    indi- 
gestion. May  have  had 
gall-stone   history. 

Periodic   or   persist- 
ent indigestion. 

Healthy ;  alcoholism, 
with  or  without  gastri- 
ns.     Gall-stone    historr 

negative. 

^e 

Chiefly  middle  age. 

Early       adult      and 
middle  age. 

Chiefly  middle  age, 
but  may  occur  from  11 
to    76. 

Bex 

Male,    in  large  pro- 
portion. 

Male,  chiefly. 

Male,  In  large  pro- 
portion. 

Chill    at    onset 

Usually  lacking. 

Usually  lacking. 

Frequently    present. 

Vomiting 

Follows     the     pain. 
Becomes      bile-stained, 
later    black    from    al- 
tered blood. 

Follows  the  onset  of 
pain.      Blood    may    be 
vomited. 

Commences  at  once 
and  is  usually  con- 
stant. Becomes  bile- 
stained  and  dark.  No 
blood  present.  No  pus 
in  early  stages. 

Thirst 

Usually  extreme. 

Less  marked. 

Very  marked  and 
often  intolerable. 

Pain 

Is    the    first    symp- 
tom, accompanied  with 
falntness  or  collapse. 

Is  the  first  symptom, 
accompanied  with  falnt- 
ness or  collapse. 

Appears  after  the 
vomiting,  and  often 
after   a   chill. 

Temperature 

Irregular,        usually 
low,  but  may  be  high. 

May     be     subnormal 
early.     Later  high. 

Likely  to  be  high 
102°    to   105°. 

Pulse 

Rapid   and   small. 

Rapid   and  small  at 
the   onset. 

From  100  to  110 
early  ;  later  very  rapid 
and    thready. 

Hiccough 

May  be  present. 

Not  prominent. 

Frequently    present. 

Bowels 

Constipation,       usu- 
ally   extreme. 

Usually  constipation. 

Either  constipation 
or    diarrhoea. 

Tenderness 

Extreme   in    epigas- 
trium. 

Extreme     in     epigas- 
trium. 

Very  marked,  but  not 
extreme. 

Tumor 

Rarely   palpable   tu- 
mor.  Increased      sense 
of  resistance  with  dis- 
tention. 

None. 

None.  But  Increas- 
ed sense  of  tissue  re- 
sistance. 

Rigidity  in  up- 
per   abdomen 

Apt  to  be  extreme. 

Extreme. 

Not       extreme,       but 
well  marked. 

Leucocytosis 

8000  to  39000. 

Averaging  20,000  to 
30,000. 

30,000    to    40,000    In 
cases   observed. 

Urine 

Sugar  may  be  pres- 
ent. 

Negative. 

Negative. 

Jaundice 

Slight    jaundice    usu- 
ally  present. 

Usually  absent. 

Slight,      In     16%     of 
cases. 

76 


Differential  Diagnosis.  The  diagnosis  must  be  made  chiefly  with 
regard  to  differentiation  from  acute  pancreatitis  and  perforated  gas- 
tric ulcer.  At  the  very  onset  it  may  simulate  acute  ptomain  or  other 
poisoning,  but  on  the  second  day  it  would  require  differentiation 
from  the  conditions  mentioned.  The  accompanying  parallel  col- 
umns will  show  the  distinguishing  symptoms  most  readily. 

It  will  be  seen  that  it  is  possible  to  make  the  diagnosis  in  the 
earlier  stages  of  the  disease,  although  it  is  but  a  narrow  shading  off 
from  the  picture  of  acute  pancreatitis.  An  accurate  history  of  the 
onset,  combined  with  a  careful  observation  of  the  several  points  of 
variation  will  throw  the  weight  of  evidence  towards  the  correct 
diagnosis.  At  any  rate,  the  diagnosis  of  an  intra-abdominal  surgical 
calamity  requiring  laparotomy  should  ordinarily  be  possible  within 
some  hours  after  the  onset  of  the  disease. 

Report  of  Writer's  Case.  My  own  case  was  that  of  H.  A.,  age 
51,  captain  of  harbor  Hghter,  married.  Previous  history  negative. 
Denies  syphilis.  No  history  of  gall-stones.  Has  had  no  pus  infec- 
tion of  any  kind  for  months  past.  Has  bad  teeth,  but  there  is  no 
trace  of  pyorrhoea  alveolaris.  Is  an  habitual  drinker,  chiefly  whiskey 
and  beer,  but  is  rarely  intoxicated.  Has  always  had  a  good  stomach 
up  to  six  months  ago,  since  when  he  has  been  inclined  to  vomit  his 
breakfast. 

Present  History.  Was  well  on  Sunday,  Jan.  27,  1908,  eating 
as  usual,  and  having  cod-fish  for  supper.  Went  to  work  on  Monday, 
and  felt  well  until  the  afternoon,  about  3  o'clock.  Was  then  seized 
with  chilly  sensations.  Went  to  bed  on  board  his  boat,  was  given  hot 
coffee  and  whiskey  and  became  warm.  At  5  o'clock  began  to  vomit 
greenish  material.  At  6  o'clock  reached  home  by  means  of  the 
street  cars,  without  assistance,  and  at  this  time  pain  commenced  in 
the  epigastrium,  and  continued  steady  and  severe.  The  pain  was  not 
relieved  by  pressure,  but  he  received  some  relief  by  steadying  the 
epigastrium  with  his  hand.  Vomited  continuously  all  that  (Monday) 
night,  and  on  Tuesday,  also  hiccoughed  steadily.  Thirst  was  extreme ; 
he  had  no  sleep  at  all  and  chills  returned.  At  noon  was  seen  by  his 
family  physician.  Dr.  W.  G.  Hirseman,  who  found  him  with  thighs 
flexed  upon  abdomen,  with  anxious  countenance,  heavily  coated 
tongue,  temperature  1005^°,  respiration  35,  pulse  85,  good  quality. 
The  abdomen  was  not  distended,  but  palpation  revealed  marked  ten- 
derness of  the  epigastrium  most  intense  to  the  right  of  the  middle 
line.  Below  the  umbilicus  deep  pressure  did  not  elicit  tenderness. 
There  was  no  icterus.  The  patient  was  given  one-fourth  grain  of 
morphine  by  hypodermic  injection,  and  a  powder  for  the  vomiting. 
On  the  return  of  the  physician  at  8  p.  m.  the  patient's  symptoms  were 
increasing,  the  abdomen  showed  slight  distention  below  the  umbilicus, 
and  marked  distention  in  the  epigastrium.  The  temperature  was 
ioi^°,  respiration  shallow,  and  pulse  100,  small,  and  intermittent. 
On  consultation  with  Dr.  L.  W.  Pearson,  the  patient  was  sent  to  the 
Brooklyn  Hospital,  as  probably  requiring  surgical  treatment. 

I  examined  the  patient  at  1 130  a.  m.,  Wednesday,  less  than  thirty- 
six  hours  from  the  time  of  onset  of  the  illness.  The  patient  was  seen 
to  be  a  man  of  large  frame,  with  every  indication  of  severe  suffering, 
complaining  of  constant  epigastric  pain,  worse  in  paroxysms,  vomit- 
ing slightly  every  minute  or  two,  and  hiccoughing.  Pulse  averaged  a 
little  over  100  and  was  regular.  Examination  showed  a  moderately 
distended  abdomen,  soft,  and  not  tender  below  the  umbilicus,  but 

77 


very  tender  above.  The  whole  epigastrium  was  tender,  but  the 
greatest  tenderness  was  to  the  right  of  the  middle  line,  at  the  point 
over  the  head  of  the  pancreas  where  greatest  tenderness  is  also 
shown  in  acute  pancreatitis.  The  flat  hand  laid  upon  the  epigastric 
area  received  a  sensation  of  resistance  or  tumor,  nearly  the  size  of 
the  palm,  but  not  of  a  high  degree  of  rigidity.  Percussion  gave 
a  tympanic  note,  extending  well  up  into  the  left  hypochondrium.  The 
combined  findings  suggested  to  my  mind  a  distended  stomach  over- 
lying a  pancreatic  tumefaction,  or  of  tumefaction  or  pus  collection 
in  the  lesser  omental  cavity.  A  few  rales  were  heard  at 
the  base  of  the  left  chest.  The  blood  test  showed  a  leucocytosis 
of  40,000.  A  diagnosis  of  an  intra-abdominal  calamity  was  made, 
strongly  suggesting  acute  pancreatitis  or  a  perforation  of  the  pos- 
terior stomach  wall,  and  operation  advised.  Examination  under  ether 
gave  the  same  impression  to  the  hand. 

Operation.  Vertical  incision  through  rectus  muscle,  four  inches 
long,  one-half  inch  to  right  of  middle  line.  Preperitoneal  fat  and 
peritoneum  seen  to  be  slightly  edematous.  Sero-pus  escaped  on 
incising  peritoneum.  Immediately,  the  stomach  wall  presented  it- 
self in  the  wound,  thickened  and  boggy,  with  highly  reddened  but 
smooth  peritoneal  coat,  showing  no  evidence  of  ulcer  or  perfora- 
tion. Further  examination  showed  a  segment  of  the  stomach  wall 
about  3>4  inches  in  breadth  to  be  involved,  the  thickening  apparently 
extending  around  the  circumference  of  the  stomach,  although  the 
thickest  part  lay  in  the  anterior  wall.  This  thickened  segment  com- 
menced with  a  well-defined  border  about  i^  inches  from  the  pylorus, 
and  the  normal  wall  of  the  pyloric  area  could  be  invaginated  with 
the  finger  into  the  thickened  segment,  and  the  thickened  wall  palpated 
in  that  manner.  The  border  of  the  thickened  segment  extending  to- 
ward the  cardia  of  the  stomach  was  less  well  defined,  and  there 
was  some  thickening  shading  off  towards  the  cardia. 

The  abdominal  incision  was  increased  to  53^  inches,  and  an 
exploration  was  made  through  the  meso-colon  into  the  lesser  sac, 
but  revealed  only  a  smooth,  thickened  posterior  stomach  wall,  gently 
adherent.  The  meso-colon  and  lesser  omentum  were  both  very 
edematous  and  thickened,  and  a  few  enlarged  lymphatic  glands  could 
be  felt  along  the  greater  curvature  of  the  stomach.  Pancreas  and 
gall-bladder  were  both  found  to  be  normal.  It  was  decided  to  incise 
the  stomach  wall  in  the  thickened  area  and  a  longitudinal  incision, 
three  inches  in  length,  was  gradually  made  down  through  the  thick- 
ened coats.  When  the  submucous  layer  was  reached,  drops  of  pus 
oozed  freely  out  of  small  openings  the  size  of  a  canary  seed.  Similar 
small  cavities,  near  the  pyloric  margin  of  the  thickened  area  were 
seen  to  be  filled  with  opaque  coagulum,  not  yet  broken  down  into 
pus.  The  stomach  wall  was  over  half  an  inch  in  total  thickness  at 
this  point.  As  far  as  the  interior  of  the  stomach  could  be  seen  and 
felt  with  the  finger  through  the  opening,  the  mucous  lining  was  deeply 
congested  and  smooth,  no  evidence  of  erosion  or  ulcer  being  found. 
The  condition  was  then  recognized  as  a  diffuse  phlegmon  of  the 
stomach  wall,  and  the  question  of  drainage  became  the  important 
one.  The  transverse  colon  was  completely  collapsed,  but  the  jejunum 
was  moderately  distended,  and  dark  bile-stained  fluid  welled  freely 
up  into  the  stomach  from  the  duodenum.  It  was  decided  to  trust 
to  a  gastrostomy  for  drainage,  leaving  the  incisions  in  the  stomach  and 
abdominal  wall  as  freely  open  as  possible.    The  drainage  tube  was  a 

78 


large  sized  stomach  tube  and  was  passed  through  the  pylorus  six 
inches  into  the  duodenum.  The  incision  in  the  stomach  wall  was 
loosely  sutured  with  a  catgut  guy-rope  suture  at  each  end  pene- 
trating only  to  the  submucous  layer  and  left  long  and  the  stomach 
lifted  up  into  the  abdominal  incision  and  held  there  by  tacking  the 
catgut  guy-rope  to  the  abdominal  wall  on  each  side  of  the  incision. 
Two  wicking  drains  were  passed  into  the  lesser  peritoneal  sac,  and 
three  large  gauze  tampons  were  packed  freely  about  the  involved  area 
of  the  stomach  to  isolate  it  in  some  measure,  and  to  drain  the  peri- 
toneal cavity.  The  abdominal  incision  was  closed  to  two-thirds  its 
extent  with  through  and  through  silk-worm  gut  sutures.  The  drain- 
age tube  was  sutured  to  the  skin  incision.  Drainage  made  its  way 
up  freely  through  the  tube  from  the  duodenum,  and  the  patient  was 
taken  back  to  his  bed  in  fairly  good  condition. 

All  vomiting  ceased  at  once  and  the  bile-stained  fluid  which 
passed  from  the  duodenum  by  siphonage  into  the  bottle  attached, 
amounted  to  many  ounces  in  the  next  twenty-four  hours.  The 
patient  was  allowed  to  suck  ice  wrapped  in  gauze  to  relieve  his  ex- 
treme thirst.  He  retained  large  quantities  of  saline  infusion  by  slow 
absorption  from  the  rectum  after  the  method  of  Murphy.  The  gauze 
tampons  in  the  abdominal  incision  drained  very  freely.  There  was 
no  leakage  from  the  stomach  about  the  tube.  The  stomach  area  was 
no  longer  tympanic  to  percussion.  The  patient  passed  good  amounts 
of  urine,  and  seemed  generally  improved,  talking  freely.  He  still 
complained  of  the  epigastric  pain,  however,  which  was  but  partially 
relieved  by  the  operation.  The  pain  came  in  marked  paroxysms, 
emanating  from  the  stomach  area,  and  not  due  to  general  periton- 
itis. 

Thirty-six  hours  after  operation,  the  upper  abdomen  was  very 
sensitive,  and  the  skin  hyperesthetic.  Abdomen  was  still  but  moder- 
ately distended,  and  but  moderately  tender  below  the  umbilicus.  Much 
drainage  persisted  from  the  wound.  Several  stitches  were  removed, 
and  the  stomach  inspected  as  far  as  possible,  and  could  be  seen  to  be 
purplish  in  color  along  the  greater  curvature.  Pulse  120.  Patient 
not  so  clear  headed,  but  he  asked  if  condition  was  serious.  On  the 
third  day  after  operation,  patient  was  still  suffering  the  paroxysmal 
pain;  conscious,  but  unable  to  speak  connectedly.  Kidneys  had 
ceased  to  secrete.  Death  ensued  3^  days  after  operation  and  5  days 
after  onset  of  attack. 

Report  of  Autopsy.  Body  well  nourished.  The  peritoneum  is 
everywhere  somewhat  injected  and  bathed  with  sero-pus,  covered  in 
spots  with  fresh  lymph.  The  intestines  are  slightly  adherent  with 
lymph.  The  appendix  is  normal.  The  mesentery  is  very  friable. 
The  meso-colon  is  inflamed,  thickened  and  covered  with  lymph.  The 
gastric-colic  omentum,  more  particularly  at  lower  curve  of  stomach, 
is  inflamed  and  edematous.  The  pancreas  is  normally  located  and 
apparently  normal  in  size  and  consistency.  Anterior  aspect 
of  the  stomach  is  intensely  hyperemic,  studded  everywhere  with 
petechiae,  covered  with  fresh  lymph  over  the  anterior  duodenal  half. 
The  mesentery  contains  a  great  deal  of  fat  and  is  somewhat  edema- 
tous. The  mucous  membrane  of  the  small  intestine  is  everywhere 
cyanosed,  somewhat  edematous,  excepting  in  the  upper  part  of  the 
jejunum  which  is  pale  and  edematous.  It  is  intact.  The  caput  coli 
is  normal.  The  mucous  membrane  of  the  larger  gut  is  moderately 
congested  and  edematous. 

79 


The  anterior  mediastinum  is  normal.  The  superficial  area  of 
cardiac  dullness  is  considerably  increased.  There  is  a  total  synechia 
of  the  left  pleural  cavity.  Also  a  total  synechia  of  the  right  pleural 
cavity,  the  adhesions  being  very  ancient  and  firm.  The  heart  is 
much  enlarged;  the  epicardium  thickened  and  opaque  and  studded 
with  petechiae  at  the  base.  The  left  auricle  is  somewhat  dilated  and 
hypertrophied.  The  auriculo-ventricular  orifice  is  large.  The  valve 
shows  a  moderate  amount  of  atheroma  anteriorly,  in  an  early  stage 
apparently;  otherwise  normal.  The  tricuspid  orifice  is  very  large; 
admits  of  four  fingers  separated.  The  valve  seems  to  be  normal. 
The  myocardium  is  considerably  thickened  in  both  ventricles,  firm  in 
consistency,  a  trifle  brownish  on  section.  All  of  the  cavities  of  the 
heart  are  markedly  enlarged:  eccentric  hypertrophy  and  dilatation. 

Lungs. — The  left  lung  is  about  normal  in  size ;  somewhat  heavy, 
crepitates  feebly  on  pressure.  On  cross-section  the  cut  surface  is 
very  dark  and  moist.  The  entire  organ  is  intensely  congested  and 
edematous.  The  right  lung  is  somewhat  enlarged,  heavy,  crepi- 
tates feebly  on  pressure.  On  cross-section  the  cut  surface  is  very 
dark  and  moist.  The  organ  is  intensely  congested  and  edematous. 
The  liver  and  the  diaphragm  on  its  under  surface  are  united  by  old 
firm  connective  tissue.  The  sub-diaphragmatic  lymph  nodes  are 
glued  together.     Diaphragm  contains  a  large  calcareous  mass. 

Spl,EEn. — The  spleen  is  large.  The  capsule  is  thick.  On  cross- 
section  the  surface  is  dark  mahogany,  moist;  the  pulp  easily  scrapes 
away;  the  trabeculae  are  somewhat  hyperplastic. 

Pancrkas. — No  edema  or  pus  in  pancreas. 

The  lower  surface  of  the  gall-bladder  is  covered  with  plastic 
lymph.    Organ  is  intact.    No  calculi. 

Liver. — The  liver  is  large,  somewhat  firm  in  consistency,  surface 
is  smooth  below  and  covered  with  old  inflammatory  tissue  above. 
On  cross-section  the  cut  surface  is  smooth  and  presents  no  further 
distinguishing  features. 

Kidneys  : — The  left  kidney  is  very  large ;  the  capsule  is  adherent 
in  spots.  Areas  of  depression  on  the  surface  of  the  organ,  which  is 
otherwise  finely  granular.  On  cross-section  the  cut  surface  is  dark 
and  cyanosed;  cortex  everywhere  swollen;  markings  distinct.  The 
right  kidney  is  small.  The  capsule  is  everywhere  adherent.  It  con- 
tains three  cystic  cavities  filled  with  serum  and  fibrim.  What  remains 
of  the  cortex  is  moderately  swollen.  The  markings  are  somewhat 
indistinct. 

Stomach. — The  stomach  is  greatly  enlarged,  the  mucous  mem- 
brane is  everywhere  thickened,  congested  in  spots,  showing  many 
petechial  hemorrhages.  The  pylorus  is  normal  as  far  as  the  mucous 
membrane  is  concerned.  The  submucosa  and  muscularis  of  the 
stomach  are  phlegmonous.  The  whole  stomach  wall  in  the  pyloric 
region  is  very  thick,  perhaps  more  than  half  an  inch.  This  condition 
involves  all  of  the  lower  aspect  of  the  stomach,  only  a  small  area 
at  the  cardiac  end  being  free.  No  evidence  whatever  of  ulceration. 
The  duodenum  is  moderately  congested,  edematous;  otherwise  free 
from  change.    The  stomach  is  free  from  pus. 

Microscopic  and  bacteriological  examinations  showed  the  pres- 
ence of  the  streptococcus.  The  streptococcus  was  also  obtained  from 
one  of  the  kidney  cysts. 

For  the  report  of  the  autopsy,  I  am  indebted  to  Dr.  J.  M.  Van 
Cott. 

80 


Analysis  of  Operative  Cases  Reported. 

There  are  but  five  -authentic  reported  cases,  in  addition  to  my 
own,  where  surgery  has  been  employed  in  acute  phlegmonous  gas- 
tritis. Of  these,  two  have  already  been  referred  to  as  being  of  the 
circumscribed  variety. 

Of  the  acute  diffuse  variety,  but  three  authentic  cases  have  been 
reported  as  having  been  operated  upon,  and  in  two  of  these  the  true 
condition  was  not  recognized  until  the  autopsy.  The  first  case  was  of 
Leith,  of  Edinburgh,  who  in  1895,  operated  several  days  after 
the  onset  under  the  diagnosis  of  general  peritonitis,  supposed  to  be 
secondary  to  typhlitis,  making  an  incision  below  the  umbilicus  and 
washing  out  and  draining  the  abdomen.  The  patient  died  in  collapse 
several  hours  after  operation.  Autopsy  showed  a  typical  acute 
phlegmon  of  the  stomach.  The  second  case  reported  was  that  of 
lycnnander,  who,  in  1898,  operated  on  a  woman  of  29,  with  a  history 
of  gastric  symptoms  dating  back  two  or  three  years,  who  gave  evi- 
dence of  a  beginning  general  peritonitis  following  a  supposed  per- 
foration of  the  stomach  or  duodenum.  No  perforation  was  dis- 
covered, the  abdomen  was  merely  drained,  and  the  patient  died  sixty 
hours  after  operation.  Autopsy  disclosed  a  diffuse  phlegmonous  gas- 
tritis involving  the  entire  organ,  the  portal  of  infection  probably  hav- 
ing been  through  two  non-perforating  ulcers  of  the  lesser  curvature. 
The  third  case  was  a  girl,  aged  13  years,  operated  on  by  J.  E. 
Adams,  St.  Thomas's  Hospital,  London,  under  the  diagnosis  of  per- 
forative peritonitis  with  general  peritonitis,  four  days  after  the  on- 
set. No  lesion  being  found  at  the  appendix,  exploration  of  the 
stomach  showed  no  adhesions  or  perforation,  but  stomach  walls  an 
inch  in  thickness  when  held  between  the  fingers.  The  condition  was 
present  throughout  the  stomach,  but  more  noticeable  in  the  pyloric 
half.  By  exclusion,  the  diagnosis  of  acute  primary  phlegmonous 
gastritis  was  made.  Beyond  drainage  of  the  peritoneum,  no  further 
operative  attempt  was  made.  The  child  lived  four  days  after  the 
operation.  Peritoneal  fluid  removed  at  operation  gave  pure  cultures 
of  the  pneumococcus,  and  cultures  made  at  autopsy  gave  the  pneu- 
mococcus  from  the  submucous  and  serous  coats  of  the  stomach. 

Included  in  the  list  of  reported  cases  of  phlegmonous  gastritis 
in  Robson  and  Moynihan's  "Surgical  Diseases  of  the  Stomach"  are 
three  cases  which  should  have  no  place  under  that  heading.  One 
of  these  (Case  84)  is  an  instance  of  perigastric  abscess  following 
an  eroding  gastric  ulcer  of  the  posterior  wall,  where  posterior  gastro- 
enterostomy was  done  by  Robson  and  recovery  ensured.  In  another 
chapter,  this  case  is  not  claimed  as  one  of  phlegmonous  gastritis,  but 
its  incorporation  with  the  list  of  cases  has  caused  misleading  quota- 
tions of  the  case  as  a  cure  of  phlegmonous  gastritis  by  gastro-en- 
terostomy.  Another  case  (No.  85)  was  an  instance  of  prolonged 
gastritis,  the  mucous  lining  only  being  involved,  the  patient  dying 
after  gastro-enterostomy,  by  the  same  operator. 

A  case  which  has  been  much  quoted  as  a  recovery  from  acute 
phlegmonous  gastritis  by  mere  abdominal  drainage  was  that  oper- 
ated upon  by  Mickulicz,  and  reported  (1902)  by  Lengemann.  The 
patient  was  a  young  woman  of  18,  with  prolonged  history  of  anemia 
and  gastric  ulcer.  Operation  was  done  with  expectation  of  finding  a 
perforation.  Bloody  serum  and  gas-bubbles  were  present  in  the 
abdominal  cavity,  but  no  perforation  was  located.  The  stomach 
was  thickened  on  its  anterior  wall,  and  two  yellowish-gray  maculae 

81 


presented  there,  each  about  the  size  of  a  silver  quarter.  No  incision 
was  made  into  the  stomach  wall,  and  the  operator  is  said  to  have 
made  his  diagnosis  on  the  symptom-complex.  Gauze  drainage  of  the 
abdominal  cavity  and  over  the  inflamed  area  of  the  stomach  brought 
about  a  prompt  recovery.  From  my  own  experience  with  an  un- 
doubted case  of  diffuse  phlegmonous  gastritis,  I  cannot  believe  that 
this  case  was  correctly  diagnosed. 

I  cannot  find,  therefore,  that  there  is  any  reliable  proof  of  the 
cure  of  diffuse  phlegmonous  gastritis  by  medical  or  surgical  means 
to  the  present  date. 

Possibilities  of  Surgical  Cure. 

One  must  admit  that  the  chance  of  a  surgical  cure  is  extremely 
small.  The  object  of  this  paper  is  to  establish  the  lines  along  which 
surgery  must  proceed  if  there  is  to  be  any  hope  of  cure.  Robson  and 
Moynihan  suggest  that  benefit  may  accrue  from  drainage  and  rest 
of  the  stomach  by  gastro-enterostomy  or  gastrostomy.  Gastro-en- 
terostomy,  I  am  sure,  would  be  an  entirely  unfit  procedure,  and  would 
only  defeat  the  end  sought  by  adding  additional  traumatism  to  the 
stomach  wall  and  further  the  spread  of  the  infection.  Gastrostomy 
would  be  also  inadequate  as  shown  by  my  own  case,  where  a  free 
incision  into  the  heart  of  the  phlegmonous  area,  and  rest  to  the 
stomach,  had  no  noticeable  effect  in  staying  the  spread  of  the  in- 
flammation. The  claim  made  by  Lengemann,  who  reported  the  case 
of  supposed  cure  by  Mickulicz,  is  altogether  without  appeal  to  surgical 
judgment.  He  states  that  the  free  drainage  of  the  peritoneal  cavity 
by  gauze  tamponade  must  have  been  sufficient  in  that  case  to  limit 
peritonitis  and  at  the  same  time  to  bring  about  a  cure  of  the  early 
require  either  the  most  complete  drainage  of  the  tissues  involved,  by 
multiple  incisions,  or  wide  excision  of  the  same.  In  my  own  case, 
case  can  surgery  hope  to  cure.  Such  treatment  would  seem  to 
drainage.  This  might  be  accomplished  by  whipping  over  the  cut 
phlegmon  of  the  stomach  wall.  There  is  no  reason  whatever  why  a 
phlegmon  confined  within  the  walls  of  any  abdominal  viscus  should 
be  cured  by  simple  drainage  of  the  peritoneal  cavity.  Mickulicz's 
case,  in  the  light  of  my  own  case,  strongly  suggests  an  induration 
of  the  stomach  wall  secondary  to  ulcer. 

My  belief  is  that  only  in  the  most  radical  treatment  of  an  early 
the  thickened  area,  though  not  broad,  extended  from  the  anterior  wall 
through  both  greater  and  lesser  curvatures,  around  nearly  a  complete 
segment  of  the  stomach,  the  posterior  wall  immediately  behind  be- 
ing also  thickened.  Multiple  incisions  down  to  the  mucosa  would 
manifestly  have  been  very  difficult  in  adequate  degree  in  my  case. 
It  is  possible  that  a  still  earlier  or  more  limited  case  than  mine  might 
be  adequately  treated  by  free  multiple  incisions  combined  with  gas- 
trostomy. The  possibility  of  having  present  a  developing  circum- 
scribed abscess  should  be  kept  in  mind  in  deciding  the  treatment, 
as  incision  should  there  suffice.  My  own  case  showed  plainly  in 
the  submucous  tissues  the  spreading  gray  lines  of  a  streptococcus 
infection  with  little  ous. 

I  believe  that  nothing  short  of  a  partial  gastrectomy  was  indi- 
cated in  my  case.  The  risks  of  such  a  step  would  have  been  ex- 
treme, but  not  entirely  beyond  hope.  The  condition  being  absolutely 
hopeless  otherwise,  one  would  be  justified  in  taking  extreme  opera- 


82 


tive  risk.  In  a  similar  case,  I  would  do  partial  gastrectomy,  adopt- 
ing at  the  start  the  usual  technique.  At  the  cardiac  end,  the  clamps 
should  be  applied  two  or  three  inches  beyond  the  marked  thickening 
if  possible.  At  the  duodenal  end,  less  distance  beyond  the  involved 
area  will  suffice,  as  the  inflammation  does  not  tend  to  attack  the 
duodenum.  After  cutting  away  the  stomach  with  knife  or  scissors, 
a  large-sized,  moderately  stiff  drainage  tube  or  catheter  should  be 
passed  several  inches  into  the  open  end  of  the  duodenum,  and  the 
latter  closed  about  it  with  purse-string  suture.  This  tube  will  an- 
swer the  double  purpose  of  drainage  of  the  duodenum,  from  which, 
in  my  case,  a  large  quantity  of  dark  fluid  constantly  welled  up,  and 
also  for  feeding  later  on,  as  in  ordinary  duodenostomy  or  jejunostomy. 
The  treatment  of  the  stump  of  the  stomach  remaining  would  be 
simply  that  of  staying  of  hemorrhage  from  the  cut  surface,  and 
drainage.  These  might  be  accomplished  by  whipping  over  the  cut 
edges  with  catgut,  and  leaving  the  cavity  unclosed,  to  be  surrounded 
with  a  gauze  pack;  or  the  walls  might  be  quickly  sutured  together 
with  catgut  for  the  most  part  of  the  opening,  and  a  large  soft 
rubber  drainage  tube  left  in  the  cardia.  A  large,  free  pack  of 
simple  gauze  left  in  the  stomach  area  might  provide  sufficient  drain- 
age of  that  space  and  the  peritoneal  cavity.  If  the  patient  recovered, 
and  were  in  fit  condition,  an  anastomosis  of  the  jejunum  with  the 
retracted  cardiac  end  of  the  stomach,  through  a  left  rectus  incision, 
might  be  done  some  weeks  later.  If  this  were  not  feasible,  life 
might  be  prolonged  by  the  duodenostomy. 

Conclusions. 

1.  Acute  diffuse  phlegmonous  gastritis  is  a  rare  form  of  inflam- 
mation of  the  wall  of  the  stomach,  involving  chiefly  the  submucous 
layer,  and  produced  usually  by  streptococcus  invasion,  locally,  or 
through  the  blood  current.  It  is  to  be  distinguished  from  local  abscess 
of  the  stomach  wall,  which  is  still  more  rare. 

2.  It  occurs  chiefly  in  middle  and  late-middle  life,  but  may 
occur  at  any  period. 

3.  It  is  to  be  distinguished  principally  from  acute  pancreatitis 
and  perforated  gastric  ulcer,  an  important  difference  being  the  on- 
set of  vomiting  before  pain. 

4.  The  prognosis  is  an  absolutely  fatal  one  unless  surgery  may 
ultimately  produce  a  cure. 

5.  Simple  gauze  drainage  about  the  stomach,  gastrostomy,  and 
gastro-enterostomy,  as  suggested  by  various  surgeons,  do  not  form 
adequate  methods  of  surgical  treatment. 

6.  Partial  excision  of  the  stomach  in  early  cases  with  duodenal 
feeding  and  gastro-enterostomy  at  a  later  stage  is  a  possible  curative 
surgical  procedure  in  early  cases. 

BIBLIOGRAPHY. 

1.  Ackerman.     Arch.  f.  path.  Anat.,  etc.,  Berlin,   1869,  ilv,   39-60. 

2.  Adams    (J.   E.).     Lancet,  Lond.,    1910,    i,    292-297. 

3.  Albers.     Med.  Cor.  Bl.  rhein.  u.  westfdl.  Aerzte,  Bonn,   1844,   206. 

4.  Andral    (S.)      Albers'   Erlauterungen,   iv,    5,    18. 

5.  Andral    (S.)    and  Cruvellhier.     Clt.  Reinking. 

6.  Andre  (E.-L.).  Arch,  de  med.  et  pharm.  mil.,  Par.,  1899,  xzxlv*  3I29>-3]SS. 
Also:  Rev.  Med.  de  Vest,  N'ancy,  1899.  xxxi. 

7.  Anikiyeff  (A.  P.).  Voyenno  med.  J.,  St.  Petersb.,  1912,  ccxzxir,  tned.-apeo. 
pt,  241-247. 

8.  Asverus   (H.).     Jenwische  Ztschr.  f.  Med.  u.  Naturw.,  Leipz.,  1866,  11,  476-482. 

9.  Auvray    (L.    A.).      *  Etude    sur    la   gastrite   phlegmoneuse,    Paris,    1866. 

10.  Baerecke  (V.  Z.).    Med.  Rec,  N.  Y.,  1898,  liv,  949-951. 

83 


11    Baird   (W.  S.).     Am.  J.  M.  Sc,  Phila.,  1911,  n.  s.,  cxlii,  648-655. 

12!  Bamberger.      Henoch    (E.).      Klinik    der    Vnterleiis-Krankheiten,    Berl.,    1855, 

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1G12. 


84 


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85 


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86 


RHINOPHYMA 

Walter  A.  Sherwood,  M.D.,  F.A.C.S., 

Surgeon  to  the  Brooklyn  Hospital. 

When  acne  rasacea  becomes  exaggerated  to  what  may  be  called 
its  third  or  extreme  stage,  an  increase  in  connective  tissue  takes  place, 
the  tip  and  sides  of  the  nose  become  converted  into  a  lobulated  mass, 
so  great  as  to  form  one  or  more  pendulous  tumors  which  overhang  the 
lip.    The  condition  is  known  as  Rhinophyma. 

Digestive  disturbance  from  whatever  cause,  producing  reflex 
dilatation  of  the  nasal  blood  vessels  and  capillaries,  is  the  basic  etiolog- 
ical factor. 

Rhinophyma  occurs  after  middle  life,  most  often  in  males  and 
usually  in  subjects  who  are  accustomed  to  rich  food  and  a  free  in- 
dulgence in  alcoholic  stimulants.  The  extreme  cases  which  require 
surgical  measures  for  their  relief  are  comparatively  rare. 

The  following  pathological  note  has  been  kindly  supplied  by  Dr. 
Nathan  T.  Beers : 

"As  the  result  of  hypemutrition  and  chronic  hyperemia  of  the 
skin  of  the  affected  parts,  the  blood  vessels  and  capillaries  become 
permanently  enlarged.  The  sebaceous  glands  are  involved  and  enorm- 
ously distended.  There  is  pronounced  hyperplasia  of  the  dermic 
connective  tissue  elements.  Nodules,  at  first  gelatinous  and  later 
fibrous  in  character,  gradually  develop.  The  increased  vascular 
dilatation  is  due  not  only  to  arterial  engorgement  but  also  to  a 
blocking  off  of  the  venous  return  as  the  result  of  follicular  suppura- 
tion and  consequent  formation  of  cicatrices." 

The  cartilage  in  some  cases  becomes  hypertrophied.  In  a  few  of 
the  cases  reported  the  growth  of  the  tumor-like  formations  has  been 
rapid.  Most  of  them,  however,  are  of  slow  growth  usually  covering 
a  long  period  of  years. 

The  condition  must  not  be  confused  with  Rhinoscleroma,  a 
chronic  granulomatous  process  affecting  the  lip,  nares  and  adjacent 
structures  and  resulting  in  sclerosis  and  nasal  deformity.  This 
disease  was  first  described  by  Hebra.  It  exists  in  the  south-eastern 
countries  of  Europe  and  is  exceedingly  rare  in  the  United  States. 

The  treatment  of  Rhinophyma  is  surgical  and  the  operative  method 
employed  will  depend  on  the  characteristics  of  the  individual  case. 

Report  of  Cass 

W.  L.,  aged  63,  was  recently  referred  to  the  writer  by  Drs.  N.  T. 
Beers  and  Raymond  Clark,  under  whose  care  he  had  been  for  the 
correction  of  other  conditions  and  for  the  purpose  of  attaining  a 
proper  degree  of  physical  fitness  in  order  that  he  might  submit 
himself  to  the  risk  of  a  general  anesthetic  and  operation. 

He  had  been  the  subject  of  an  increasing  nasal  deformity  which 
had  started  as  an  acne  rasacea  about  twenty-five  years  ago.  During 
the  last  year  the  size  and  unsightliness  of  the  condition  had  increased 

87 


so  rapidly  as  to  be  a  matter  of  extreme  embarrassment  to  himself, 
his  family  and  his  friends.  The  appearance  of  the  man  when  he  pre- 
sented himslf  is  well  shown  in  the  accompanying  photographs  (Figs. 
1,  2  and  3). 

The  enormous  enlargement,  the  overhanging  lobulated  masses 
and  the  wide-open  crypts  of  the  sebaceous  glands  are  well  illustrated. 
The  entire  organ  presented  a  deep,  purplish  red  appearance  with 
enormously  engorged  blood  vessels. 

After  careful  consideration  of  the  several  methods  of  attacking 
such  a  condition  it  was  decided  to  remove  completely  the  diseased 
tissues  and  cover  in  the  resulting  raw  surface  with  suitable  skin  grafts 
at  one  sitting.  The  method  employed  was  practically  the  same  as 
that  described  by  Binnie  in  his  work  on  operative  surgery. 

The  patient  was  referred  to  the  service  of  the  writer  at  the 
Brooklyn  Hospital  where  the  following  procedure  was  carried  out : 

Warmed  ether  vapor  by  Dr.  Gwathmey  administered  through  a 
mouth  canula  under  pressure  of  a  motor-driven  pump. 

Step  1. — Gauze  tampons  introduced  through  nares  to  prevent 
inflow  of  blood  into  the  naso-pharynx. 

Step  2. — With  the  forefinger  of  the  left  hand  in  the  nostril  as  a 
guide,  an  incision  was  made  all  around  the  growth  from  the  middle 
line  outward.  A  straight  incision  was  then  made  through  the  mid- 
line from  above  downward.  These  were  carried  down  to  but  not 
into  the  cartiliage  (Fig.  4). 

Step  3. — The  edge  of  the  tumor  mass  was  grasped  with  forceps 
and  all  the  diseased  tissues  within  the  line  of  incision  were  cut  away 
first  on  one  side  and  then  on  the  other  (Fig.  5).  Care  was  taken  to 
preserve  the  normal  outline  of  the  nostril  and  to  prevent  the  knife 
from  entering  the  cavity  of  the  nares.  The  hypertrophied  cartilage 
was  shaved  off  with  a  knife  until  it  assumed  normal  proportions. 

Step  4. — Hemorrhage,  which  of  course  was  very  profuse  and 
continuous,  was  controlled  by  pressure,  hot  pads  and  the  ligation  of 
the  larger  vessels. 

Step  5. — The  raw  surface  was  then  covered  with  good-sized 
Thiersch  grafts  (Fig.  6)  taken  from  the  outer  side  of  the  patient's 
arm.  The  principal  steps  of  the  operation  will  be  readily  understood 
from  the  accompanying  drawings. 

The  grafts  were  covered  with  silver  foil,  a  dry  gauze  com- 
press applied  and  the  parts  protected  from  injury  by  the  application 
of  a  rubber  nose  guard  such  as  is  used  by  football  players. 

All  dressings  were  removed  on  the  fifth  day,  the  grafted  area  was 
dusted  with  aristol  and  left  exposed  to  the  air  and  sunlight.  Serous 
exudate  was  considerable  and  as  the  result  of  it  a  hard  dry  crust 
formed  and  covered  the  entire  nose.  This  was  in  no  way  disturbed 
until  two  weeks  had  elapsed  when  it  was  softened  with  cold  cream  and 
gradually  and  carefully  peeled  off  with  forceps.  It  was  found  that  all 
grafts  had  retained  their  vitality.  The  process  of  epithelial  repair  was 
very  rapid,  and  at  the  end  of  three  weeks  the  entire  nose  was  com- 
pletely covered  with  a  new  healthy  skin  of  a  color  corresponding  to 
the  rest  of  the  face.  The  parts  were  smooth,  the  contour  of  the  nose 
was  normal,  and  there  was  very  little  scar  formation   (Fig.  7). 

The  appearance  of  the  nose  has  steadily  improved  and  now  ap- 
pears as  in  Fig.  8. 

The  chief  difficulties  of  such  an  operation  are  as  follows: 

1.  The  proper  choice  of  an  anesthetic  and  method  of  administer- 

88 


Fig.  1. — Rhinophyma.   Condition   before  operation.     Front  view. 


Fig.  2. — Rhinophma.     Condition  before  operation.     Side  view. 


Fig.  3. — Rhinophyma.     Condition  before  operation.     Anterolateral  view. 


Fig.  4. — Rhinophyma.      Incisions   of  operation. 


Fig.  S. — Rhinophyma.     Method  of  removing  tissue. 


Fig.    6. — Rhinophyma.      Wound    covered    with    skin — grafts    after    removed 

of  diseased  tissue. 


Fig.  7. — Result  after  operat.ion  for  rhinophyma. 


Fig.  8. — Result  after   operation   for   rhinophyma. 


ing  it.     Rectal  anesthesia  is  ideal  for  such  operations  but  was  not 
deemed  advisable  in  this  case. 

2.  The  danger  of  hemorrhage  and  difficulty  of  controlling  it  dur- 
ing the  dissection  of  the  tissues. 

3.  The  density  of  the  tissues  and  absence  of  any  line  of  cleavage 
makes  dissection  tedious  and  favors  wounding  the  cavity  of  the 
nares. 

4.  The  uncertainty  of  the  healing  process. 

The  result  obtained  was  so  satisfactory  and  gratifying  to  all 
concerned,  that  it  would  seem  to  warrant  the  brief  report  herewith 
presented. 


The  photographs  are  published  by  permission. 


89 


VIII 
THE  NORV^EGIAN  HOSPITAL. 


CANCER  OF  THE  RECTUM. 

H.  Beeckman  Delatour,  M.D.,  F.A.C.S., 

Surgeon-in-Chief  to  the  Norwegian  Hospital. 

URGERY  of  the  abdominal  viscera  through  improvements  of 
technique  and  added  experience  of  operators  has  been  deprived 
of  many  of  its  former  complications  and  is  attended  by  a  con- 
stantly diminishing  mortality.  Operations  on  the  pelvic  organs  and  the 
appendix  have  long  since  become  commonplace.  Within  the  past 
few  years  surgery  of  the  upper  abdomen,  the  stomach,  liver,  and  gall 
bladder  has  been  extended  and  perfected,  and  today  is  approached 
with  much  more  confidence  than  formerly. 

Malignant  disease  of  the  intestine,  however,  has  been  much  neg- 
lected and  operations  have  been  postponed  until  acute  symptoms,  such 
as  obstruction,  have  developed  and  forced  interference.  During  the 
past  three  or  four  years  these  Cctses  have  been  diagnosed  in  the  earlier 
stages  and  more  radical  operations  are  being  undertaken  with  a  marked 
reduction  of  operative  mortality  and  a  very  decided  gain  in  permanent 
cures. 

Cancer  of  the  rectum  has  been  the  subject  of  operative  attack  for 
many  years,  but  the  methods  employed  were  such  that  many  cases 
were  passed  over  as  inoperable  or  were  so  operated  that  not  suffi- 
cient bowel  was  removed  to  insure  a  permanent  result.  The  hesitancy 
of  the  surgeon  to  produce  an  artificial  anus  has  passed  many  a  case 
on  to  a  period  of  prolonged  suffering  and  ultimate  death.  "I  would 
rather  die  than  have  an  artificial  anus,"  is  a  statement  we  have  fre- 
quently heard  and  given  expression  to  ourselves.  The  very  idea  of 
it  is  repugnant.  This  feeling  has  delayed  our  progress  in  the  treat- 
ment of  malignant  disease  of  the  sigmoid  and  rectum  and  been  re- 
sponsible for  the  infliction  of  prolonged  suffering  on  many. 

Inexperience,  tending  to  high  operative  mortality,  has  also  been 
a  factor  in  leading  one  to  pass  upon  a  given  case  as  inoperable.  Very 
interesting  in  this  connection  is  the  paper  of  Mayo  in  which  he  com- 
pares the  percentage  of  operable  cases  at  their  clinic  at  different 
periods  and  also  the  operative  mortality  of  the  same. 

During  the  period  from  1893  to  1910,  there  was  an  operative  mor- 
tality of  17.8  per  cent.;  from  1910  to  1913,  it  was  17.17  per  cent, 
with  an  operability  of  51  per  cent.  During  this  period  only  about 
one-half  the  cases  examined  were  considered  subjects  for  a  radical 
operation. 

For  the  years  1913,  1914  and  1915,  the  mortality  averaged  12.5 
per  cent,  and  the  operability  71.8  per  cent.,  while  the  operations  were 
made  more  radical.  During  this  period  nearly  three-quarters  of  the 
cases  examined  were  operated,  upon.  With  further  experience  and 
due  care  in  selecting  cases  the  mortality  will  be  lowered  and  the  per- 
centage of  cures  increased. 

Early  diagnosis  is  the  keynote  of  success,  but  we  must  con- 
stantly bear  in  mind  that  cancer  of  the  bowel  is  slower  of  metastasis 

93 


than  cancer  in  other  portions  of  the  body,  and  that  many  apparently 
advanced  growths  can  be  successfully  removed  with  a  long  period  of 
immunity  from  recurrence  and  possibility  of  permanent  cure.  In 
doubtful  cases  exploratory  operation  is  certamly  justifiable,  and 
should  be  performed  in  cases  of  persistent  intestinal  conditions  m 
patients  beyond  thirty-five  years  of  age,  when  other  means  have  failed 
to  reveal  the  cause  of  the  symptoms. 

We  must  not  wait  for  emaciation  and  cachexia  to  develop,  for  in 
these  cases  they  appear  late  and  the  patient  is  then  quite  likely  in  the 
inoperable  stage. 

Having  made  the  diagnosis  of  cancer  of  the  lower  bowel,  what 
shall  be  our  method  of  attack?  Shall  it  be  from  the  perineum, 
through  sacral  section,  by  the  abdominal  route  or  by  a  combination 
of  these?  This  must  depend  somewhat  on  the  individual  case,  but  no 
operation  should  be  undertaken  unless  it  is  sufficiently  radical  to  elimin- 
ate the  disease.  The  frequency  of  recurrence  in  the  past  has  been 
due  to  a  too  great  desire  to  retain  the  anus  in  its  normal  position, 
and  the  sooner  the  surgeon  can  realize  that  this  should  be  the  last 
consideration  the  quicker  shall  we  see  an  increased  percentage  of  last- 
ing cures. 

It  is  our  belief  that  very  few  cases  can  be  satisfactorily  operated 
by  either  the  perineal  or  sacral  routes  alone ;  and,  further,  the  ab- 
dominal part  of  the  operation  is  of  immense  importance  in  permitting 
a  thorough  exploration  of  lymph  glands  and  liver  to  determine  the 
amount  of  extension  of  the  disease.  If  there  is  positive  evidence  of 
involvement  of  the  liver,  no  radical  excision  should  be  undertaken. 
Enlargement  of  the  lymph  glands  does  not  contraindicate  operation, 
for  in  many  cases  these  glands  are  found  to  be  the  seat  of  a  simple 
inflammatory  process  and  not  due  to  extension  of  the  growth. 

If  an  artifical  anus  has  to  be  produced,  should  we  endeavor  to 
place  this  in  the  perineum  or  on  the  abdomen?  Careful  watching  of 
several  cases  has  convinced  us  that  the  abdominal  anus  is  the  more 
easily  cared  for  by  the  patient.  The  perfection  of  the  technique  of 
producing  the  abdominal  anus,  and  teaching  the  patient  its  proper 
care  together  with  the  application  of  a  correctly  fitted  apparatus  have 
so  reduced  the  disagreeable  features  of  this  condition  that  we  no  longer 
hesitate  to  advise  our  patients  to  accept  the  operation. 

The  abdominal-perineal  operation  in  either  one  or  two  stages  is 
our  preference,  and  of  late  we  have  been  better  satisfied  with  the 
one  stage  operation  in  those  patients  in  whom  a  sufiicient  time  could 
be  given  to  preliminary  preparation.  In  cases  of  obstruction,  either 
complete  or  nearly  so,  a  preliminary  colostomy  should  be  done  in 
order  that  the  bowel  may  be  properly  emptied  and  cleansed,  for  the 
mortahty  is  largely  due  to  sepsis  from  escape  of  feces  during  opera- 
tion. 

The  method  of  procedure  varies  with  different  operators,  but  a 
careful  study  fails  to  reveal  any  very  radical  differences.  The  most 
recent  descriptions  are  those  of  Jones  of  Boston,  and  Cofifey  of  Port- 
land. The  method  of  Coffey  we  have  never  attempted  as  it  does  not 
seem  practicable. 

The  operation  which  we  have  followed  during  the  past  four  years 
in  eight  cases  without  any  operative  mortality  and  so  far  no  recurrence, 
is  similar  to  that  described  in  the  text  books. 

Operation:  With  the  patient  well  elevated  in  the  Trendelenburg 
position,  the  abdomen  is  opened  in  the  median  line  and  an  exam- 

94 


ination  of  the  extent  and  location  of  the  growth  is  made ;  the  liver 
is  also  examined  for  evidences  of  involvement.  The  intestines,  ex- 
cept the  sigmoid,  are  then  carefully  placed  in  the  upper  abdomen  and 
protected  by  a  large  gauze  pad,  thus  leaving  the  pelvis  clear  for  our 
manipulations. 

The  sigmoid  is  now  lifted  out  and  its  mesentery  traced  to  the 
promontory  of  the  sacrum  where  the  inferior  mesenteric  artery  can 
be  felt.  The  peritoneum  is  then  incised  and  the  vessel  ligated  in 
two  places,  between  the  upper  and  middle  sigmoid  branches,  and  the 
artery  divided.  This  insures  proper  blood  supply  to  the  proximal 
sigmoid  which  is  to  be  used  for  the  colostomy.  By  further  separation 
of  the  peritoneum  to  the  left,  the  left  ureter  is  exposed.  The  mesen- 
tery is  then  divided  from  behind  forward  up  to  the  edge  of  the 
bowel.  The  incision  through  the  peritoneum  is  now  carried  down- 
ward parallel  to  the  bowel  and  about  one  inch  from  it  to  the  bottom 
of  the  pelvic  pouch  and  then  these  incisions  are  joined  across  the  front 
of  the  bowel.  By  blunt  dissection  with  the  fingers  the  rectum,  to- 
gether with  the  mass  of  fat,  is  separated  from  the  hollow  of  the  sac- 
rum, down  to  and,  if  possible,  beyond  the  coccyx.  If  the  vessels  have 
been  ligated  above,  this  is  accompanied  by  very  little  bleeding.  The 
next  step  is  to  free  the  bowel  from  the  bladder  and  prostate,  and  in 
doing  this  great  care  has  to  be  exercised  not  to  injure  the  ureters. 
The  dissection  from  above  is  carried  down  as  far  as  possible  for  this 
simplifies  greatly  the  second  stage  of  the  operation.  The  division  of 
the  bowel  is  not  made  until  all  dissection  has  been  completed.  A  large 
gauze  sponge  is  now  packed  in  the  pelvis  and  soon  stops  any  oozing 
that  may  be  taking  place. 

Two  clamps  are  now  placed  on  the  bowel  at  the  point  selected 
for  division,  the  bowel  is  severed  by  the  actual  cautery  and  both  ends 
inverted  and  closed  by  silk  suture.  The  gauze  pack  is  next  removed 
from  the  pelvis,  and  the  distal  portion  of  the  sigmoid  and  rectum 
placed  in  the  pelvis  and  covered  with  a  small  gauze  pad.  The  edges  of 
the  divided  peritoneum  are  next  sutured  by  continuous  chromic  suture 
over  the  pelvis,  thus  excluding  it  from  the  general  peritoneal  cavity. 

Where  the  amount  of  bowel  to  be  removed  was  too  large  to  pack 
into  the  pelvis  and  permit  suture  of  the  peritoneum  over  it,  we  have 
removed  a  large  segment  of  the  freed  portion,  after  properly  closing 
the  lumen  by  heavy  silk  ligature  and  then  dividing  with  the  cautery. 

We  next  proceed  to  the  production  of  the  colostomy  as  follows: 
A  sufficient  amount  of  bowel  is  brought  forward  so  that  about  two 
inches  will  project  beyond  the  skin,  the  bowel  is  then  sutured  to  the 
peritoneum  in  the  upper  portion  of  the  wound,  the  fibres  of  the  rectus 
muscle  are  separated  and  the  anterior  sheath  divided  and  through  this 
the  end  of  the  intestine  is  passed  and  brought  out  beyond  the  skin 
where  it  is  fastened  by  several  silk  sutures.  After  final  cleansing  of 
the  abdominal  cavity  the  wound  is  closed  in  layers  and  a  gauze  dressing 
applied.  The  sutures  closing  the  lumen  of  the  bowel  are  left  in  place 
and  the  bowel  is  not  opened  until  from  the  third  to  the  fifth  day.  The 
method  of  producing  a  colostomy  described  by  Brinsmade  has  given 
very  satisfactory  results;  as  yet  we  have  not  used  it. 

The  further  steps  of  the  operation  may  now  be  carried  out  if  the 
patient's  condition  will  permit,  or  may  be  delayed  for  several  days. 
As  this  procedure  rarely  takes  more  than  eight  to  ten  minutes  it  can 
usually  be  carried  out  at  once.  The  patient  is  put  in  the  lithotomy  posi- 
tion with  the  pelvis  well  elevated,  the  anus  is  surrounded  by  an  incision 

95 


through  the  skin  and  then  closed  by  a  strong  silk  suture.  The  levator 
ani  is  next  divided  and  the  rectum  separated  from  the  prostate  or 
uterus  in  front  and  the  remaining  tissues  attaching  it  to  the  COCC30C 
divided.  The  free  end  of  the  sigmoid  can  now  usually  be  seized  and 
brought  through  the  wound  and  the  remainder  of  the  section  be  done 
from  above  downward.  There  is  usually  very  little  hemorrhage,  the 
only  vessels  of  importance  being  those  near  the  skin  and  easily 
reached.  In  this  way  from  fifteen  to  twenty  inches  of  the  bowel  are 
removed.  The  gauze  pack  is  now  removed,  the  wound  dried  out  and 
the  large  cavity  remaining  is  lightly  packed  with  zinc  oxide  gauze  and 
the  anterior  portion  of  the  perineal  wound  closed  by  interrupted  silk 
sutures.  If  thought  best  the  uterus  and  adnexa,  or  portion  of  prostate 
can  be  rem.oved  as  a  part  of  the  procedure. 

The  after-care  consists  in  irrigation  and  repacking  of  the  lower 
wound  as  is  necessary.  The  opening  of  the  bowel  is  delayed  for  sev- 
eral days  so  as  to  avoid  infection  of  the  abdominal  wound.  In  cases, 
where  necessary,  a  large  drainage  tube  may  be  sewn  into  the  bowel 
and  the  free  end  placed  in  a  bottle  so  that  the  discharge  is  collected 
without  soiling  the  wound. 

The  extra  portion  of  bowel,  one  and  a  half  to  two  inches,  project- 
ing above  the  skin  can  be  cut  down  to  the  level  of  the  skin  at  any  time 
without  anaesthesia.  We  believe  the  leaving  of  this  for  several 
days  to  be  an  excellent  plan  because  sloughing  of  some  of  the  bowel 
occasionally  takes  place  and  then  the  opening  is  brought  too  close  to 
the  skin  line. 

After  recovery  the  patient  is  fitted  with  our  permanent  colostomy 
cup  which  enables  him  to  go  about  his  business  without  fear  of  soil- 
ing his  clothing  and  without  the  presence  of  disagreeable  odors. 

This  operation,  which  has  given  in  our  hands  an  immunity  of 
over  eight  years  in  one  case,  and  others  still  free  of  recurrence  at  vari- 
ous periods  over  two  years,  with  no  mortality  in  the  last  eight  cases 
and  with  comparative  comfort  to  all  during  those  years,  strongly 
appeals  to  us  when  we  recall  the  sufferers  we  have  seen  in  the  later 
stages  of  the  disease.  These  poor  sufferers  are  in  a  deplorable  con- 
dition, reduced  to  mere  skeletons,  suffering  intense  agony,  with  con- 
stant tenesmus  and  a  continuous  foul  rectal  discharge.  The  odor  is  so 
offensive  that  they  are  avoided  by  their  families.  Their  condition  is 
worse  than  death.  Let  us  make  every  effort  to  reach  these  people  early 
and  save  them  this  miserable  existence. 


96 


IX 


SAINT  MARY'S  HOSPITAL. 


GASTROJEJUNOSTOMY  WITH  CLOSURE  OF  THE  DUO- 
DENUM AND  CHOLECYSTOSTOMY. 

Onslow  A.  Gordon,  M.D.,  F.A.C.S., 

THE  case  here  reported  is  considered  worthy  of  record  because 
of  the  fact  that  the  pylorus  having  been  closed  by  a  simple 
method  remains  impervious  at  the  end  of  sixteen  months. 
The  patient,  thirty-nine  years  old,  referred  to  me  by  Dr.  M.  L. 
Bodkin,  had  suffered  from  "indigestion"  for  about  two  years.  She 
complained  of  pain  in  the  epigastric  region  often  associated  with  nausea 
and  vomiting.  The  pain  was  usually  relieved  by  taking  food  and 
alkalies.  Her  vomiting  usually  occurred  about  two  hours  after  meals 
and  was  as  a  rule  sour  and  burning.  She  had  on  two  occasions  vomited 
almost  clear  blood  and  had  noticed  blood  in  her  stools.  Dur- 
ing the  past  year  she  had  lost  forty  pounds.  With  this  classical  his- 
tory and  physical  and  laboratory  findings  substantiating  it,  the 
diagnosis  was  apparent.  She  was  operated  on  June  4,  19 15.  The 
patihiology  found  at  operation  was  an  indurated  ulcer  just  to  the  gas- 
tric side  of  the  pylorus  and  a  gall-bladder  containing  several  calculi. 
The  ulcer  was  treated  by  a  posterior  gastrojejunostomy  with  exclusion 
of  the  pylorus.  The  gall-bladder  was  drained  after  the  usual  manner. 
The  interest  in  this  case  of  course  centers  in  the  subject  of  exclusion  of 
the  pylorus.  The  advisability  of  closure  of  the  duodenum  has  not  been 
definitely  established  and  advocates  of  this  procedure  are  not  at  all 
agreed  as  to  the  most  desirable  method.  In  this  case  the  pylorus  was 
closed  by  the  simple  method  advocated  by  Berg.  A  heavy  linen  purse- 
string  suture  was  carried  around  the  posterior  stomach  wall  at  the 
pylorus  and  then  tied,  thus  closing  off  the  duodenum.  This  closure 
has  remained  permanent  up  to  the  present  time,  a  period  of  six- 
teen months,  as  shown  by  radiographs. 

The  patient  made  an  uneventful  and  complete  recovery  and  since 
operation  has  gained  about  fifty  pounds  in  weight  and  apparently  is 
in  perfect  health. 


99 


X 

THE  PILCHER  PRIVATE  HOSPITAL. 


PAIN  DUE  TO  ANATOMICAL  DEVIATION  OF  THE 

URETER. 

Paul  Monroe  Pilcher,  A.M.,  M.D. 


TO  determine  the  cause  of  pain  referred  to  the  abdomen  or  to 
the  back  is  often  a  difficult  problem.  When  the  pain  comes  on 
unexpectedly  in  the  night  without  a  previous  history  of  some 
definite  disorder,  we  think  of  many  lesions  which  might  give  rise 
to  it.  The  occurrence  of  nausea,  vomiting  and  frequency  of  urina- 
tion is  so  common  an  accompaniment  of  most  attacks  of  colicky 
pain  that  they  often  simply  tend  to  confuse  the  picture. 

In  our  search  for  evidence  we  palpate  the  abdomen;  we  examine 
the  urine  and  blood ;  we  take  the  temperature ;  we  examine 
the  pelvis ;  we  take  radiographs,  and  when  all  is  done  we  may  be  still 
in  doubt.  However,  there  are  still  more  delicate  tests  which  may 
be  employed.  They  consist  of  a  combination  of  special  methods  and 
instruments.  I  refer  to  the  stomach  tube,  the  Bismuth  meal,  the  Bis- 
muth enema  and  the  x-ray  in  stomach  and  intestinal  lesions ;  the 
blood  test  for  cholesterol,  urinary  analysis,  and  the  x-ray  for  gall 
stones;  and  the  cystoscope,  the  ureter  catheter,  the  x-ray  and  pyelog- 
raphy in  obscure  lesions  of  the  kidney,  kidney  pelvis  and  ureter.  Add 
to  these  a  mind  trained  to  interpret  these  combined  findings  and  a 
correct  diagnosis  is  the  result,  where  fonnerly  an  exploratory  opera- 
tion was  resorted  to,  and  only  too  often  failed  to  reveal  the  lesion. 

During  the  past  year  several  cases  have  been  referred  to  our 
clinic  complaining  of  recurring  pain  in  the  hypochondrium  and  lum- 
bar region,  often  extending  downward  to  the  lower  right  or  left 
abdominal  region.  Those  patients  in  whom  pus  or  macroscopic  blood, 
or  tubercle  bacilli  have  been  found  in  the  urine  coming  from  the 
ureter  of  the  affected  side,  have  been  relatively  easy  of  diagnosis,  es- 
pecially when  a  radiograph  has  shown  the  presence  of  a  calculus  at 
the  pelvo-ureter  junction,  or  in  the  ureter. 

In  most  of  the  remaining  cases,  gall  bladder  disease,  ulcers  of 
the  stomach  and  intestines — aneurysms — spinal  disease — and  tubo 
ovarian  and  uterine  lesions  can  be  excluded  as  the  cause  of  the  pain. 

There  remain  chiefly  the  chronic  lesions  arising  from  the  ap- 
pendix and  a  condition  frequently  mistaken  for  appendicitis,  namely 
intermittent  dilatation  of  the  renal  pelvis  due  to  anatomical  deviation 
of  the  ureter,  and  a  small  class  of  cases  due  to  stricture  of  the  ureter 
and  perinephritis.  The  acute  inflammatory  lesions  are  not  easily  con- 
fused with  any  of  these  disorders. 

The  cases  of  anatomical  deviation  of  the  ureter  include  chiefly 
those  due  to  high  implantation  of  the  ureter  into  the  renal  pelvis, 
twists  and  kinks  of  the  ureter  due  to  undue  mobility  of  the  kidney  and 
the  first  portion  of  the  ureter,  and  the  very  important  class  of  cases  in 
which  a  set  of  aberrant  blood  vessels  cross  the  ureter  and  enter  the 
lower  pole  of  the  kidney  and  form  a  loop  over  which  the  ureter  bends 
and  becomes  obstructed. 

103 


The  diagnosis  of  such  a  condition  can  be  made  before  operation 
with  considerable  exactness ;  but  oftentimes  it  involves  an  extended 
study  of  the  case,  and  even  when  it  is  suspected  after  taking  the  his- 
tory, examination  may  lead  to  the  discovery  of  other  lesions  as  a 
cause  of  the  pain. 

The  possibilities  of  diagnosis  and  the  means  employed  to  establish 
the  same  are  well  shown  in  the  following  case  reports : 

Ii^i^usTRATivE  Cases. 

Case  I.  Clinic  No.  1,976.  Referred  by  Dr.  H.  M.  LowenthaL 
Diagnosis:  Intermittent  hydro-pelvo-nephrosis ;  obstruction  of  ureter 
due  to  aberrant  blood  vessels  with  kink  and  twist  of  ureter. 

Chief  Symptoms:  Recurrent  pain  in  right  hypochondrium  and  the 
right  lower  quadrant  of  the  abdomen. 

Patient  is  a  young  nervous  girl,  aged  23,  who  seven  years  ago 
began  to  have  pain  in  the  right  side  coming  on  in  the  evening  and 
lasting  for  about  two  hours.  If  she  worked  too  hard,  or  was  very 
nervous,  pain  would  appear  in  the  right  hypochondrium.  It  would 
come  on  sharply  and  would  disappear  suddenly.  Latterly  the  pain 
has  been  more  severe  and  she  has  needed  some  morphine  to  control 
it.  There  has  been  no  disturbance  of  any  of  the  essential  systems  of 
the  body.  Her  nutrition  is  good  and  the  bowels  are  regular.  There 
are  no  symptoms  referable  to  the  stomach  or  lungs.  No  bladder 
symptoms.  Pain  always  starts  in  the  same  spot  in  the  right  hypo- 
chondrium with  severe  colic-like  pain  which  passes  through  to  the 
back,  very  similar  to  that  observed  in  gall  stone  colic.  After  the  sever- 
ity of  the  pain  has  passed,  the  soreness  remains  and  feels  like  a  sore 
tooth.  Pain  is  more  apt  to  come  on  when  she  is  tired,  but  does  not  seem 
to  have  direct  connection  with  exercise,  and  no  connection  with  eating, 
gas  formation  in  the  bowels,  or  her  menstrual  periods.  After  awhile 
the  pain  goes  away  and  she  passes  an  increased  amount  of  water,  or 
at  least  she  goes  more  frequently  to  pass  her  water. 

Lately  the  pain  has  been  more  severe.  She  has  an  attack  every 
two  or  three  weeks.  Two  weeks  ago  had  an  attack  which  lasted  all 
day  and  into  the  next  day.  At  first  there  is  a  gnawing  feeling  in  the 
right  side  and  sense  of  pressure,  then  developes  severe  colic,  and 
now  there  is  a  continual  sense  of  distress  in  that  side. 

The  condition  has  repeatedly  been  diagnosed  as  appendicitis  and 
she  has  repeatedly  been  advised  to  have  her  appendix  removed  but 
the  operation  has  been  refused. 

Physical  examination  showed  no  abnormahties  with  the  exception 
that  the  right  upper  quadrant  of  the  abdomen  examined  during  the 
time  the  patient  was  having  pain,  showed  the  presence  of  a  fairly 
large  mass  in  the  region  of  the  kidney  and  gall  bladder  presenting 
beneath  the  free  border  of  the  ribs.  There  is  some  tenderness  over 
the  cecum. 

Examination  of  the  urine — acid,  1020,  no  albumin,  no  sugar  and 
no  abnormal  microscopical  findings. 

From  the  history  of  the  case,  the  age  of  the  patient,  the  peculiar 
character  of  the  attacks,  the  long  duration  of  the  attacks,  the  ab- 
sence of  urinary  findings,  the  absence  of  any  gastro-intestinal  dis- 
of  various  types,  the  most  probable  diagnosis  in  this  case  is  an  inter- 
turbance,  such  as  excessive  fermentation,  constipation  and  indigestion 
mittent  hydro  pelvo  renalis,  due  to  anatomical  deviation  of  the  ureter 

104 


1 


Fig  1.  Uretero-pyelogram  in  Case  1.  Showing  de- 
formity of  ureter  and  "egg  shaped"  dilatation  of  renal 
pelvis.     Pilcher  Clinic. 


Fig.  2.  Outlines  of  kidney  and  ureter  in  Case 
1.  Note  oblique  axis  of  kidne}^  Uretero-pyelo- 
gram. 


Fig.   3.     Artist's   interpretation   of   the   pyelograph   in 
Case   1.     Pilcher   Clinic. 


Fig.  4.  Dilated  renal  pelvis  due  to 
anatomical  deviation  of  ureter  (aber- 
rant blood  vessel).  Incision  exposing 
kidney  showing  dilated  pelvis  present- 
ing in  w^ound.     Case  1. 


Fig.  5.  Dilated  renal  pelvis  showing 
aberrant  blood  vessels  crossing  ureter 
causing  constriction.  Showing  position 
of  hand  grasping  kidney  to  accentuate 
deformity.  Aberrant  vessels  (Ab)  have 
already  been  cut — consisting  of  an  ar- 
tery and  two  veins  entering  lower  pole 
of   kidney.     Case   1. 


Fig.  6.  Dilated  renal  pelvis  due  to 
anatomical  deviation  of  ureter.  Later 
step  in  operation  after  blood  vessels 
have  been  divided  and  dissected  free 
from  ureter.  In  'cases  of  long  standing 
a  permanent  impression  has  been  made 
upon  the  ureter  with  thickening.  The 
probe  should  be  passed  from  above 
downv/ard  beyond  point  of  obstruction 
and  a  suitable  size  soft  bougie  passed 
from   above  into  the  bladder. 


Fig.    7.     Pyelograph    of    the    ureter    and    renal 
pelvis  in  Case  2. 


caused  either  by  an  aberrant  blood  vessel  or  a  fixed  portion  of  the  ure- 
ter kinked  by  prolapse  of  the  kidney.  In  a  case  of  this  kind  we  can 
exclude  chronic  appendicitis  and  prolapsed  or  enlarged  twisted  cecum, 
on  account  of  a  definite  lack  of  intestinal  symptoms.  Stone  in  the 
kidney  is  also  possible,  but  may  be  excluded  by  x-ray  examination. 
But  a  stone  present  in  the  pelvis  or  right  ureter  for  a  period  of  seven 
years  would  give  absolute  changes  in  the  urine,  which  we  did  not 
find  in  this  case. 

The  indications  for  the  examination  are — first,  an  x-ray  of  the  kid- 
ney and  second,  a  pyelograph  of  the  pelvis  of  the  kidney. 

Further  examination  was  made  on  October  21,  1915. 

Radiograph  taken  by  Dr.  James  Pilcher  showed  right  kidney  to 
be  normal  in  size,  but  its  axis  was  oblique.  There  was  no  stone  present 
in  the  kidney,  or  its  pelvis,  or  its  ureter. 

Argentide  picture  of  the  right  ureter  and  kidney  showed  the 
right  ureter  to  be  normal  in  size  until  it  reached  a  point  opposite  the 
transverse  process  of  the  first  lumbar  vertebra,  where  it  is  constricted 
and  twisted  about.  The  argentide,  hov/ever,  passes  by  the  obstruc- 
tion and  dilates  the  kidney  so  that  the  picture  is  that  of  a  typical  egg- 
shaped  pelvis  which  is  pathognomonic  of  an  intermittent  hydro-pelvo- 
renalis,  due  to  constriction  or  aberrant  blood  vessels.     (Figs.  1,  2,  3.) 

In  examining  the  pyelographs  it  will  be  seen  that  none  of  the 
calyces  are  visible  and  this  is  so  because  the  relaxed  walls  of  the 
hydronephrotic  sac  are  not  distended  to  their  full  capacity.  The  kid- 
ney itself  lies  between  the  free  border  of  the  ribs  and  the  crest  of  the 
ilium. 

Cysioscopic  examination  revealed  the  fact  that  the  left  kidney  was 
present  and  secreting  normal  urine. 

Operation,  exposing  right  kidney  (Fig.  4).  It  was  found  pro- 
lapsed and  in  an  oblique  position  wnth  a  dilated  pelvis.  A  set  of  aber- 
rant vessels  was  found  crossing  the  ureter,  as  indicated  in  the  radio- 
gram, consisting  of  a  fairly  large  artery  and  two  veins,  as  in  the 
accompanying  drawings.  The  artery  was  ligated  and  divided  and  in 
addition  was  dissected  away  from  the  ureter.  (Fig.  5)  It  was  found 
that  there  was  some  constriction  of  the  ureter  beneath  this  attached 
vessel.  The  pelvis  which  was  greatly  dilated  was  separated,  a  large 
probe  passed  down  through  the  ureter  dilating  it.  (Fig.  6)  A  plastic 
operation  on  the  pelvis  of  kidney  was  done;  the  kidney  fixed  in 
normal  position  and  the  wound  sutured. 

Patient  made  an  uneventful  recovery  and  has  never  had  any  re- 
currence of  symptoms  since  that  time. 

Cask  II.  Male.  Referred  by  Dr.  Warren  L,.  Duffield.  Diagnosis: 
Intermittent  hydro-pelvo-nephrosis ;  obstruction  of  ureter  due  to  aber- 
rant blood  vessels  causing  kinking  of  ureter. 

Abstract  of  History:  Patient  nineteen  years  of  age.  Six  years 
ago  began  to  have  attacks  of  pain  in  region  of  right  kidney,  not  very- 
severe,  radiating  to  testicle  and  bladder.  Lasting  about  two  days. 
Attack  comes  on  gradually,  becomes  more  severe,  dull  ache  and  then 
disappears.  These  spells  come  on  at  least  every  two  weeks,  and  are 
described  as  attacks  of  severe  cramplike  pain  in  the  right  side  beneath 
the  free  border  of  the  ribs,  frequently  brought  on  by  violent  exercise, 
riding  on  trains,  etc.    Generally  comes  on  in  the  middle  of  the  night. 

His  urine  has  been  examined  by  several  physicians  who  stated  that 
he  had  pyelitis.   Aside  from  the  pain  there  have  been  no  symptoms  of 

105 


renal  disease.  Bowels  regular ;  no  indigestion ;  sleeps  well,  but  nervous. 
This  is  practically  all  of  his  history. 

In  other  words,  he  has  recurrent  attacks  of  pain  in  the  right 
hypochondrium  referred  to  the  right  lumbar  region,  extending  down 
toward  the  bladder.  The  region  of  the  kidney  is  tender  during  these 
attacks.  The  patient  is  becoming  more  and  more  limited  in  his 
activities. 

Urine  Acid;  1018;  trace  of  albumin;  small  amount  of  blood; 
many  large  round  epithelial  cells  and  crystals. 

Cystoscopy:  Urine  collected  from  right  kidney  showed  many  blood 
cells,  probably  traumatic ;  large  number  of  granular  and  renal  epithelia. 

X-ray  of  kidney  negative. 

Argument:  By  exclusion,  all  of  the  more  common  lesions  were 
eliminated.  Our  only  positive  signs  were  the  few  blood  cells  in  the 
urine  and  pain  in  the  region  of  the  right  kidney,  for  the  x-ray  picture 
was  negative.  Therefore,  a  pyelograph  of  the  right  kidney  and  ureter 
was  taken  and  showed  that  the  right  ureter  was  very  markedly  kinked, 
forming  a  hairpin  curve  opposite  the  pelvis  of  the  kidney,  and  that  it 
entered  the  pelvis  of  the  kidney  abruptly.  A  second  picture  showed 
an  egg-shaped  dilatation  of  the  pelvis  of  the  kidney  (Fig.  7).  On  this 
evidence  a  diagnosis  was  made  of  intermittent  dilatation  of  the  renal 
pelvis  due  to  obstruction  of  the  ureter  caused  by  aberrant  renal  blood 
vessels. 

Operation  was  advised  and  undertaken  by  Dr.  Duffield.  The 
exact  anatomical  conditions  as  outlined  in  the  argument  were  found 
by  him  at  operation.  The  blood  vessels  were  divided  and  the  ureter 
which  had  been  very  markedly  kinked  immediately  straightened  out. 
The  kidney  was  fixed  in  a  high  position  and  the  patient  made  a  good 
recovery. 

Cass  III.  Male.  Referred  by  Dr.  Arthur  H.  Bogart.  Diagnosis: 
Intermittent  hydro-pelvo-renalis  due  to  anatomical  deviation  of  the 
ureter. 

Patient  twenty-two  years  of  age.  Main  points  in  history  were 
that  the  patient  had  suffered  from  attacks  of  pain  referred  to  the  right 
side  of  the  abdomen  mostly  in  the  lumbar  region.  First  attack  came 
on  suddenly  in  the  middle  of  the  night,  in  February,  1914,  very  severe 
and  suggestive  of  renal  origin.  There  was  frequency  of  urination. 
Second  attack  ten  months  later  came  on  during  the  day.  Pain  started 
in  the  back  and  radiated  to  the  front.  At  first  the  pain  was  severe, 
then  moderated.  There  was  increasing  frequency  of  urination.  X-ray 
examination  negative.  Several  attacks  followed.  Was  in  hospital  for 
three  weeks  under  observation,  as  the  result  of  which  he  was  oper- 
ated upon  for  possible  appendicitis,  and  a  kinked,  diseased  appendix 
was  removed.  However,  attacks  recurred  immediately.  Further 
x-rays,  wax  tipped  catheters  and  many  examinations  at  another  clinic 
failed  to  reveal  the  cause  of  his  symptoms.  A  study,  however,  of  the 
x-ray  plates  demonstrated  that  the  kidney  occupied  an  oblique  posi- 
tion; that  its  axis  was  not  perpendicular  which  it  should  be  in  the 
normal  state;  also  that  the  kidney  descended  through  an  arc  of  fully 
two  inches  and  that  the  hepatic  flexure  of  the  colon  was  prolapsed. 
Further,  that  there  occurred  regularly  a  spasm  at  the  hepatic  flexure 
(Fig.  8),  which  would  account  for  pain  in  the  region  of  the  cecum. 

A  pyelogram  of  the  right  kidney  (Fig.  9),  was  taken  under 
anesthesia  and  it  revealed  an  irregular  dilatation  of  the  pelvis  of  the 

106 


Fig.  8.  Radiogram  of  cecum  and  hepatic  flexure 
in  Case  3.  Showing  spasm  of  section  of  gut 
at  flexure.     Appearing  on   several   plates. 


Fig.  9.     Outlined  pyelogram  of  kidney  in  Case 


Fig.  10.  (2096j  Reproduction 
of  x-ray  taken  in  Case  3  at  Dr. 
Eastmond's  Clinic  showing  pro- 
lapse of  hepatic  flexure,  pro- 
lapse of  right  kidney  and  change 
in  the  kidney  axis.  Dotted  line 
A  is  the  normal  axis  of  the  kid- 
ney. Dotted  line  B  is  the  axis 
of  the  kidney  shown  in  the  x-ra3\ 


[^liH^^^ 


Fig.    11.     Pyelogram   in    Case   5.      Showing   normal 
ureter   and   kidney   pelvis. 


right  kidney  with  the  calyces  of  the  kidney  moderately  dilated.  A 
positive  diagnosis  of  intermittent  dilatation  of  the  pelvis  of  the  kidney 
with  anatomical  deviation  of  the  ureter  was  made.  Previous  to  this 
time  pain  had  centered  more  over  the  region  of  the  appendix  and  low 
down  in  the  pelvis. 

Argument:  The  symptoms  in  this  case  were  very  severe  first,  pain 
in  the  region  of  the  kidney,  later  most  marked  over  the  cecum;  some 
frequency  of  urination  during  attacks;  a  few  blood  cells  in  the  urine; 
some  rigidity  of  the  right  rectus  muscle  during  these  attacks. 

The  patient  was  operated  upon  by  Dr.  Bogart.  A  moderate 
dilatation  of  the  pelvis  of  the  kidne  ywas  found.  The  kidney  was 
sutured  in  a  high  position.  No  aberrant  blood  vessel  demonstrated. 
Patient  made  a  good  recovery  and  has  been  well  since  that  time. 

Case  IV.    Female.    Referred  by  Dr.  Walter  D.  L,udlum. 

Diagnosis:  Intermittent  dilatation  of  pelvis  of  kidney  due  to  kink- 
ing of  ureter  in  a  case  of  ren  mobilis.  Partial  volvulus  of  ascending 
colon. 

Some  cases  are  complicated  by  intestinal  lesions.  It  is  very  im- 
portant to  search  these  out  in  order  to  do  complete  surgery  when  any- 
thing is  attempted.  This  patient  complained  of  pain  in  the  right  hypo- 
chondrium  and  the  right  lumber  region,  quite  typical  of  renal  disturb- 
ance. These  attacks  were  severe  and  recurrent,  passing  down  to  the 
region  of  the  cecum.  The  attacks  of  pain  in  the  right  side  came  on  at 
intervals  of  months,  but  there  were  no  evidences  of  disease  demonstra- 
ble in  the  urine.  In  addition,  she  gave  a  very  distinct  history  of  in- 
digestion supposed  to  be  due  to  gastric  ulcer;  was  persistently  con- 
stipated. 

Radiogram  showed  the  presence  of  a  rudimentary  rib,  a  prolapse 
of  the  hepatic  flexure  and  prolapse  of  the  right  kidney. 

A  pyelograin  showed  a  very  slight  dilatation  of  the  pelvis  of  the 
right  kidney,  but  no  change  in  the  calyces  of  the  kidney.  Negative 
for  stone. 

Cystoscopic  examination  showed  an  accumulation  of  urine  in  the 
pelvis  of  the  right  kidney. 

Argument:  A  case  with  such  a  history  demands  more  than  a 
diagnosis  of  intermittent  dilatation  of  the  renal  pelvis,  and  further 
examination  revealed  a  prolapsed  dilated  cecum. 

Operation  was  undertaken.  The  kidney  was  found  to  be  prolapsed 
and  freely  movable.  It  was  raised  up  and  fixed  in  good  position.  Then 
the  abdomen  was  opened  through  a  right  rectus  incision.  A  prolapsed 
and  partially  rotated  cecum  was  found  together  with  a  markedly 
dilated  caput  with  a  long  appendix.  A  plastic  operation  was  done  on 
the  cecum,  and  the  ascending  colon  was  brought  up  into  its  normal 
position  and  sutured  there.  As  a  result,  the  patient  made  a  good 
recovery  and  was  relieved  of  her  lumbar  and  lower  abdominal  pain. 
There  are  now  no  symptoms  of  her  original  indigestion  and  her  bowels 
move  regularly  without  cathartics. 

Case;  V.  Patient  presenting  symptoms  similar  to  those  found  in 
cases  of  intermittent  dilatation  of  the  renal  pelvis  due  to  anatomical 
deviation  of  the  ureter,  hut  really  due  to  conditions  of  the  colon  and 
pelvic  organs.  A  woman,  twenty-four  years  of  age,  whose  chief  symp- 
tom had  been  persistent  pain  in  the  left  hypochondrium  passing 
around  to  the  back  and  down  toward  the  bladder.    She  stated  that  the 

107 


pain  came  on  suddenly  and  v/as  described  as  a  general  abdominal 
pain  which  later  resolved  itself  into  a  colicky  pain  referred  to  the  left 
hypochondrium  and  left  lumbar  region.  She  usually  vomited  with 
these  attacks  and  demanded  morphin  to  control  the  pain.  The  attacks 
recurred  with  increasing  frequency.  Was  sent  to  another  clinic  and 
remained  there  for  two  months  without  diagnosis  and  returned  home 
still  suffering  from  the  pain.  The  chief  features  of  her  illness  while 
in  the  hospital  were  vomiting  and  pain. 

The  diagnosis  first  suggested  by  the  symptom  complex  was  an  ob- 
struction of  the  ureter  with  pain  originating  in  the  kidney. 

Urinalysis  showed  an  acid  reaction,  sp.  gr.  1.020,  trace  of  albumin, 
no  sediment. 

Radiographs  of  the  kidney  were  negative. 

Vaginal  examination  showed  tenderness  in  the  left  fornix.  Trac- 
tion on  the  cervix  caused  pain  referred  to  left  hypochondrium. 

Radiographs  of  the  colon  demonstrated  a  deformity  of  the  cecum 
and  transverse  colon,  confining  a  fecal  mass  in  the  cecum;  also  show- 
ing the  presence  of  adhesive  bands  binding  together  a  portion  of  the 
transverse  colon  and  ascending  colon. 

A  pyelogram  of  the  left  kidney  and  ureter  was  taken  and  no  ab- 
normality was  found.     (Fig.  11.) 

Evidently  the  kidney  must  be  excluded  as  the  cause  of  the  pain. 

With  the  definite  lesions  known  to  exist  in' the  first  portions  of  the 
large  intestine,  the  patient  was  again  questioned  as  to  her  early  his- 
tory, and  it  developed  that  at  first  she  had  suffered  entirely  from 
pain  on  the  right  side.  This  pain  had  come  on  suddenly,  was  accom- 
panied by  vomiting  and  fever  and  was  very  suggestive  of  acute  ap- 
pendicitis. The  left  sided  pain  evidently  originated  in  the  left  tube  and 
ovary. 

The  abdomen  was  opened  and  a  chronically  deformed  appendix 
was  removed.  The  ascending  and  transverse  colon  v^^ere  freed  from 
the  adhesions  which  bound  them  together.  A  plastic  operation  was  per- 
formed on  the  left  uterine  adnexa  and  some  adhesions  extending  to 
the  sigmoid  colon  were  divided. 

The  patient  made  a  good  recovery  and  has  been  entirely  relieved 
of  her  symptoms. 

In  concluding  this  brief  clinical  report  the  writer  wishes  to  em- 
phasize the  fact  that  the  diagnosis  of  pain  due  to  anatomical  deviation 
of  the  ureter  can  rarely  be  made  from  a  consideration  of  the  clinical 
symptoms  alone,  or  by  the  aid  of  examinations  made  in  the  laboratory. 
One  must  depend  more  upon  the  various  mechanical  aids,  such  as 
the  pyelograph  and  the  cystoscope,  basing  our  final  judgment,  how- 
ever, on  the  combined  evidence  collected  from  interrogation  of  the 
patient,  a  personal  examination  of  the  patient,  the  laboratory  reports, 
and  the  interpretation  of  the  scientific  aids  to  our  special  senses,  the 
cystoscope  and  the  x-ray. 


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